[Senate Hearing 110-1]
[From the U.S. Government Publishing Office]



                                                          S. Hrg. 110-1
 
                 DOD/VA COLLABORATION AND COOPERATION 
             TO MEET THE NEEDS OF RETURNING SERVICEMEMBERS
=======================================================================


                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            JANUARY 23, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate



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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                            JANUARY 23, 2007
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
    Prepared statement...........................................     2
Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho....     3
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia...     4
    Prepared statement...........................................     4
Murray, Hon. Patty, U.S. Senator from Washington.................     5
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     7
Sanders, Hon. Bernard, U.S. Senator from Vermont.................     8
Webb, Hon. Jim , U.S. Senator from Virginia......................    52
Obama, Hon. Barack, U.S. Senator from Illinois...................    56
    Prepared statement...........................................    56

                               WITNESSES

Mansfield, Hon. Gordon H., Deputy Secretary, Department of 
  Veterans 
  Affairs........................................................     9
    Prepared statement...........................................    12
    Response to written questions submitted by:
        Hon. Daniel Akaka........................................    18
        Hon. John D. Rockefeller IV..............................    24
        Hon. Barack Obama........................................    28
Chu, Hon. David S.C., Under Secretary of Defense for Personnel 
  and Readiness, Department of Defense...........................    30
    Prepared statement...........................................    32
    Response to written questions submitted by:
         Hon. Daniel Akaka.......................................    39
        Hon. John D. Rockefeller IV..............................    44
        Hon. Barack Obama........................................    45
        Hon. Larry E. Craig......................................    47
        Hon. Arlen Specter.......................................    49
        Hon. Lindsey O. Graham...................................    50


  DOD/VA COLLABORATION AND COOPERATION TO MEET THE NEEDS OF RETURNING 
                             SERVICEMEMBERS

                              ----------                              


                       TUESDAY, JANUARY 23, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:36 a.m., in 
room SR-418, Russell Senate Office Building, Hon. Daniel K. 
Akaka, Chairman of the Committee, presiding.
    Present: Senators Akaka, Rockefeller, Murray, Obama, Brown, 
Webb, Tester, Sanders, and Craig.

   OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, U.S. 
                      SENATOR FROM HAWAII

    Chairman Akaka. The hearing of the Committee will come to 
order. I want to welcome the Members who are here for this, our 
first hearing, and also our witnesses, and I look forward to 
the responses that will be forthcoming.
    I want you to know that this is the Committee's first 
hearing for the 110th Congress, and I look forward to working 
with our new and returning Members for this to be a productive 
session. I also want to say I am delighted to continue to work 
with Senator Craig. We have had such a good relationship, and 
we will continue to work in a bipartisan manner, as we have, 
and I look forward to working with him and with Members of this 
Committee.
    Today's hearing will focus on cooperation and collaboration 
between the Departments of Veterans Affairs and Defense. There 
has been strong congressional interest dating back to the 1980s 
on improving how the two Departments work together on improving 
the transition process. We hope to hear today on where the two 
Departments are and where they need to be.
    I want to thank Secretary Mansfield from VA and Secretary 
Chu from DOD for joining us today. Today's hearing will 
establish a benchmark for future hearings and will focus on 
specific health and benefits issues that relate to the two 
Departments. Where opportunities exist for sharing resources 
that benefit servicemembers and veterans, they must be seized. 
With tens of thousands of servicemembers in harm's way, it is 
more important than ever that the Departments work together.
    The Departments must facilitate the seamless transition of 
servicemembers from active duty to veteran status. Prior to 
separation, servicemembers must know exactly how they can 
obtain the benefits and services available to them. This must 
be true whether someone is separating from active duty, the 
Guard, or Reserves. It is especially vital for those who are 
wounded or severely injured.
    I can only imagine the stress that a new veteran with a 
life-altering wound or injury endures when faced with 
transitioning from one health care system to another while 
still in the process of recovery and rehabilitation. The 
handoff between the Departments for those who are in the 
greatest need must be truly seamless.
    According to the Office of Management and Budget, there has 
been slippage since 2002 in the progress of implementing 
coordination of VA and DOD programs and systems. This is deeply 
concerning. It appears to me that much of this slippage has 
resulted from a failure to identify who is responsible for 
implementing recommended actions to improve cooperation and 
collaboration between the Departments. This perception is 
consistent with the 2003 report of the President's Task Force 
to Improve Health Care Delivery for Our Nation's Veterans and 
by numerous GAO reports. VA and DOD must take advantage of 
local successes by implementing lessons learned on a national 
level.
    Let me be clear. There have been successes, and I 
congratulate the Departments on those areas where progress has 
been made. I hope that our witnesses today will help us 
understand what areas still require work. If there are 
particular areas where this Committee or Congress can be of 
help, I ask that you let us know.
    I have a longer statement that I will place in the record, 
and that is available at the press table. In the interest of 
time and to allow others to speak, I will end my remarks at 
this time.
    [The prepared statement of Senator Akaka follows:]
         Prepared Statement of Hon. Daniel K. Akaka, Chairman, 
                        U.S. Senator from Hawaii
    Good morning and welcome to the Committee's first hearing for the 
110th Congress. As I said at our organizational meeting, I look forward 
to working with our new and returning Members, and for this to be a 
productive session for our Committee.
    Today's hearing will focus on the current level of cooperation and 
collaboration between the Department of Veterans Affairs and the 
Department of Defense. There has been strong Congressional interest, 
dating back to the 1980s, on improving how the two Departments work 
together and improving the transition process. We hope to hear from our 
witnesses today, where the two Departments are and where they need to 
be.
    I thank Secretary Mansfield from VA and Secretary Chu from DOD for 
joining us today to testify on this important subject. It is my hope 
that their testimony will establish a benchmark for future hearings 
that will focus on specific health and benefits issues that relate to 
the two Departments.
    It only makes sense that, where opportunities exist for sharing 
resources that benefit servicemembers and veterans, we take advantage 
of these opportunities. As a senior member of the Armed Services 
Committee, I have looked at the issue of seamless transition from the 
vantage point of the military, and now, as Chairman of this Committee, 
I will look at it from the VA perspective. Today, with thousands of 
servicemembers in harm's way, it is more important than ever that the 
Departments work together.
    The issue of the Departments working together goes beyond the 
sharing of resources. It must also include efforts to facilitate the 
seamless transition of servicemembers from active duty to veterans 
status. There is no reason why servicemembers, prior to separation, do 
not know exactly what VA can do for them and how they can obtain the 
benefits and services available to them. Given the current worldwide 
involvement of the total force, I believe strongly that the message 
needs to be consistent and universally understood by all, regardless of 
whether they are separating from active duty, the Guard or Reserves. 
This is especially true for those who are wounded or severely injured. 
I can only imagine the stress that a new veteran with a life altering 
wound or injury endures when faced with the challenge of transitioning 
from one health care system to another while still in the process of 
recovery and rehabilitation. I am sure it would be a daunting task 
under the best of circumstances. We need to ensure that the hand-off 
between the Departments for those who are in the greatest need is truly 
seamless. This is an area where we cannot improve enough.
    According to the Office of Management and Budget, there has been 
slippage since 2002 in the progress of implementing coordination of VA 
and DOD Programs and Systems. This is deeply concerning. It appears to 
me that much of this slippage has resulted from a failure to identify 
who is responsible for implementing recommended actions that could 
result in improved levels of cooperation and collaboration between the 
Departments. This perception is consistent with the 2003 report of the 
President's Task Force to Improve Health Care Delivery for our Nation's 
Veterans and by numerous GAO reports. In my view, the two Departments 
are not making enough progress on a national level. I believe that VA 
and DOD can take better advantage of local successes, by implementing 
them on a national level.
    Let me be clear--there have been successes and I congratulate the 
Departments on those areas where progress has been made, including the 
degree to which the Departments share information, cooperate on 
transition issues, and deliver benefits and services.
    I hope that our witnesses today will help us understand what areas 
that still require work, and provide us with their respective 
Departments' strategic plans on how they intend to improve the level of 
coordination and collaboration between the Departments and ensure that 
servicemembers truly have a seamless transition to VA. If there are 
particular areas where this Committee or the Congress can be of help, I 
ask that they let us know.

    Chairman Akaka. I would like to ask our Ranking Member, 
Senator Craig, for his remarks.
    Senator Craig?

       STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER, 
                    U.S. SENATOR FROM IDAHO

    Senator Craig. Well, Mr. Chairman, thank you very much, and 
also let me apologize for being late. That will not happen 
again. I always appreciate, as I know you do, getting these 
hearings started on time.
    Let me also thank you for your lead-off on this very 
important issue. It is clearly something that we and the Nation 
must focus on to make sure that those who have served and are 
transitioning out receive the benefits and the kind of 
continued treatment needs that are important.
    As you know, 2 years ago we held a series of hearings on 
this issue. The survivors' transition hearings revealed 
confusion among survivors about the array of Federal benefits 
and services available to them and inconsistent service 
provided by military casualty officers.
    I am particularly interested in this issue, and I look 
forward to the hearing on the update today from DOD on the 
implementation of a uniform policy of casualty assistance that 
all of its service branches are using and whether the 
customized, integrated Web site on Federal survivor benefits is 
eliminating survivor confusion.
    Next in the series, the Committee examined the health care 
transition process of seriously combat-wounded servicemembers. 
Many of these veterans were caught in the long-term limbo 
awaiting discharge from the military. We learned about the 
specific treatment challenges, such as early intervention for 
mental health care and outreach to those in need of family 
therapy services. I remain somewhat concerned that DOD's 
efforts to take care of its own are making the coordination of 
care and benefits between DOD and VA more difficult.
    Third, we held hearings on what steps VA, DOD, and the 
Department of Labor were taking to ease the transition process 
by providing veterans benefits such as disability compensation, 
vocational rehabilitation, and employment placement and 
training services. I hope to hear today that our returning 
servicemembers are being made aware of these benefits, that 
there is adequate follow-up to ensure a successful transition, 
and that seriously wounded combat servicemembers are being 
afforded some priority of service.
    And, finally, we held a field hearing following the return 
from Iraq of 1,700 of my fellow Idahoans with the Army National 
Guard 116th Cavalry Brigade. These Guardsmen and reservists did 
not return to an Army base in Georgia or an Air Force base in 
Mountain Home, Idaho. Instead, as we all know, the Guard and 
Reserve units returned to their homes, and to civilian lives, 
in some respect, and to their regular job. I hope to hear today 
the update on how well we are doing in that regard in relation 
to the transition and where VA can step in at that point once 
they are out of active service and make available re-employment 
rights or assuring that those kinds of things continue to 
happen, as we will probably continue to need to use Guard and 
Reserve for the near future.
    ``Seamless transition,'' in my opinion, is a very broad 
term that encompasses efforts by a number of different agencies 
and programs, and even includes making immediately accessible 
the medical records of the servicemember who is transferred 
from military treatment facilities to veterans' medical 
centers. We are all proud of how the VA handles its medical 
records now. We need to make sure that there is a completion of 
process, that there are not shortcomings there as these two 
agencies work to make that happen.
    So I am pleased that you led with this issue, Mr. Chairman. 
I think it is tremendously important to our servicemen and 
women as they transition into civilian life or as they move 
from one care for their injuries to another care.
    Thank you very much.
    Chairman Akaka. Thank you very much, Senator Craig.
    I would like to ask Jay Rockefeller for his statement.

           STATEMENT OF HON. JOHN D. ROCKEFELLER IV, 
                U.S. SENATOR FROM WEST VIRGINIA

    Senator Rockefeller. Mr. Chairman, if I have your 
permission, I will put my statement into the record.
    Chairman Akaka. Thank you very much, Senator Rockefeller.
    [The prepared statement of Senator Rockefeller follows:]
          Prepared Statement of Hon. John D. Rockefeller IV, 
                    U.S. Senator from West Virginia
    Chairman Akaka and Ranking Member Craig, I want to thank you for 
your dedication and commitment to oversight and bipartisanship--both 
are enormously important. I look forward to working closely with you. 
We truly have a moral obligation to meet the needs of our veterans--
both those returning from combat today, and our older veterans from 
previous eras.
     The plans and reports on DOD/VA coordination and collaboration are 
important and vital. I appreciate your efforts to get the formal plans 
and agreements in place and underway.
     But, as encouraging as the testimony is today, this is not what I 
hear when I talk privately with West Virginia soldiers at roundtables 
back home. It is not what my caseworkers hear from veterans and their 
families in calls to our office. I believe we are making a good start, 
but there must be the adequate funding commitments and top leadership 
to make the promises of collaboration work. A promise made to veterans 
must be kept.
     We need to push harder to help our veterans with cooperation and 
coordination. Given the nature of the combat and the huge stress 
involved, we must improve our mental health services and our outreach 
for such services. I support the VA effort to expand both the staff and 
the number of Vet Centers to serve our veterans. I also want to work 
with Chairman Akaka to give our National Guard and Reservists 5 years 
of access to VA care, instead of the current 2 years.
     Plus, we must take additional efforts to help our National Guard 
and Reservists who in recent years have been playing a bold and 
extraordinary role in our Armed Services. We need to recognize this and 
deal with unique challenges facing our Guard and Reserves, as well as 
their families.

    Chairman Akaka. At this time I would like to ask Senator 
Murray for her statement.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Chairman Akaka and Senator Craig, thank you 
very much for holding this hearing. This is exactly the type of 
oversight and accountability we need to have to make sure our 
servicemembers get the services they need when they come home. 
And as I can tell you, we have got a lot of work to do. From 
the veterans I have talked to, it is clear that we do not offer 
them a seamless transition from the battlefront to the 
homefront, and that has really got to change.
    If we have a seamless transition, why are so many veterans 
coming home without jobs? Why are so many veterans unable to 
get housing? We have new reports out today that say that up to 
1,000 veterans from Iraq and Afghanistan are homeless today. 
That is unacceptable.
    If we have a seamless transition, why are veterans having 
to wait 6 months to see a VA doctor for primary care? Why are 
so many veterans having trouble getting help with PTSD? On 
Friday, in fact, our Army's top medical officer said that some 
returning troops are not getting the help they need, and to me 
that is unacceptable.
    If we have a seamless transition, why are so many Guard and 
Reserve members unable to get help from the efforts like the 
Transition Assistance Program? Why are our Vet Centers 
overwhelmed with veterans seeking help? Why do our veterans 
have to wait 2\1/2\ months to see a mental health care 
professional when they return from combat?
    We do not need a hearing to discover if we have a seamless 
transition. I know that we do not. And we do not need this 
hearing to find out if the Pentagon and the VA are working 
together enough. I do not think they are. We do need to use 
this hearing to find out from our witnesses what they are doing 
about it and how they are going to fix it.
    And I can tell you one thing: The veterans I talk to do not 
really care about Washington, DC, talk. They care about the 
reality they see in my State and across the Nation, whether 
they can get a job, whether they can get health care, whether 
they can get the benefits they need. And that should be the 
test we all use.
    If we do want to make progress, Mr. Chairman, I think we 
need to understand how we got here so we can change course. How 
did we get to a point where, 4 years into this war, we have a 
2-year backlog for VA benefits, mental health care that is 
inaccessible, and long lines to see a VA doctor? We had better 
understand how we got here so that we do not make the same 
mistakes moving forward.
    Mr. Chairman, the first problem is that the Bush 
Administration did a miserable job planning for the aftermath 
of the war. The failures we have seen in the planning on the 
military side are mirrored by failures of planning on the VA 
side. We all know that the VA has some of the best employees in 
the world, and we are very proud of the work they do. But for 
too long, we have had a VA leadership that has not done an 
adequate job planning for the many veterans this war is 
creating, and the VA is still woefully behind in its 
projections.
    Last year, the VA planned to see 110,000 veterans from Iraq 
and Afghanistan. It ended up seeing more than 185,000. For this 
year, the VA projects to see 109,000 veterans, fewer than they 
saw last year. That does not make sense. We need an accurate 
plan from the VA that spells out the real needs and how the VA 
intends to meet those needs.
    The second problem is that the Bush Administration has 
never made a commitment to fund veterans' health care as an 
essential part of the cost of war. This war is being paid for 
by supplementals, but those supplementals do not include 
funding for veterans' health care. Funding for veterans' health 
care has gone up, but it is still not tied to the real needs. 
We need to get the VA and the White House to match the funding 
to what the real needs are so our veterans are not left behind.
    And the third problem, Mr. Chairman, is that we have not 
been able to get straight answers or real numbers out of the 
VA. The GAO has found in report after report that VA has misled 
Congress, concealed funding problems, and based its projections 
on inaccurate models. That has to change because our veterans 
are paying the price.
    With all due respect to our witnesses, other officials from 
your agencies have sat at that very same table and assured us 
that everything was fine, when it certainly was not. I was 
assured many times that the VA had the funding it needed, only 
to learn later that the VA had a $3 billion shortfall and the 
agency had falsified budget savings over many years.
    So, today, Mr. Chairman, I hope we hear from Dr. Chu and 
Mr. Mansfield that you realize that there are serious problems 
on the ground and that you are committed to solving them.
    We are having this hearing at a very critical moment. The 
President has proposed escalating our military involvement in 
Iraq. Just 4 days ago, the VA Secretary told the Houston 
Chronicle that sending more than 20,000 troops into Iraq will 
not have an impact on the VA's backlog of claims. Secretary 
Nicholson described the impact of the surge on the VA as 
``minimal.''
    Well, I stood here in the Senate with nine veterans last 
week from the Iraq war, and they had a much different picture 
of that. They believe that the President's escalation will 
further degrade our ability to care for our veterans. Today, 
without the surge, veterans are waiting for the services that 
they have been promised. If we are not meeting the veterans' 
needs of today, how can we keep the promise to troops who are 
sent to an escalated war?
    Tonight the President is going to deliver his State of the 
Union speech. During last year's speech, the President did not 
mention the word ``veteran'' once. I hope tonight finally he 
does talk about our veterans and acknowledges that our VA is 
overwhelmed and underfunded and outlines his plans for meeting 
our troops' needs when they return home.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Brown?

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman. Thank you for the 
work that you and Senator Craig have done on behalf of the 25 
million veterans in this country. And, Senator Murray, thank 
you for your very poignant statement and what you have done for 
veterans in your State and in this country.
    There are more than a million veterans in my State of Ohio. 
When I am out talking to veterans, I hear several themes stand 
out: one, barriers to health care and long-term care; two, 
claims that languish for months, as Senator Murray said, 
without response; three, inadequate job and educational 
opportunities; and, four, unfair cuts in widow and other 
survivor benefits.
    In addition to these critical concerns, this Committee, as 
we have talked, Mr. Chairman, needs to pay attention to 
problems facing those veterans who may not come to our offices 
or who may not write us letters or whom we may not see as we 
are home in our States--those who are homeless, those who are 
in physical and emotional crises after sustaining a 
debilitating injury, those who are struggling with severe 
mental illness. Our Committee should spearhead efforts to fully 
fund the VA health care system to enhance VA mental health care 
and to abolish the disabled veterans tax which cuts pensions 
for those on disability pay.
    We should work to enhance educational and housing 
opportunities for veterans, as envisioned in the G.I. Bill for 
the 21st century. We should push for tax cuts for businesses 
who continue to pay servicemembers serving extended tours, and 
we should work to ensure that Reservists and Guardsmen can 
enroll their families in the TRICARE program on an affordable 
basis.
    We should advocate on behalf of widows and survivors and 
repeal the military families tax which reduces survivor 
benefits for family members of those who die of service-related 
injuries.
    Understanding we are working under daunting budget 
constraints and against a host of competing Federal priorities, 
but our Nation has made a promise to provide key benefits and 
service to veterans, and no priority overrides our obligations 
to fulfill that promise.
    Last week, I visited injured soldiers from my State at 
Bethesda. One of them has a pretty certain future, one of the 
soldiers I visited. One Marine has a pretty uncertain future, 
suffering from head injury. I am not at all confident, once he 
leaves Bethesda, that our military and our VA will track him 
well enough to be able to anticipate what problems his head 
injury may lead to as he tries to go back to work, as he tries 
to live a normal life.
    I am hopeful that our witnesses today can give all of us 
the confidence that the VA is really prepared, as this war 
escalates, as more troops come home with psychological and 
physical illnesses and injuries, that they will be ready to 
take care of the people to whom we have an obligation once they 
return to their homes.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Brown.
    Senator Sanders?

              STATEMENT OF HON. BERNARD SANDERS, 
                   U.S. SENATOR FROM VERMONT

    Senator Sanders. Thank you, Mr. Chairman, and I will be 
brief, because there is not much that I can add to what Senator 
Murray and Senator Brown and others have said.
    When I was first elected to the Congress 16 years ago in 
the House, one of the things that I did was hold town meetings, 
many town meetings around the State of Vermont in order to 
inform veterans of the benefits to which they were entitled to. 
And the reason I did that is because we found that many, many, 
many thousands of veterans simply did not know the benefits to 
which they were entitled to such as the prescription drug 
program. And as a result of that, thousands of veterans entered 
into the VA system.
    Mr. Chairman, if we go to war, I think what we have to 
understand is that the cost of war does not stop the day that 
the war ends. The cost of war stops when the last veteran stops 
needing the benefits and the help that they should receive as a 
result of their service to this country.
    And let me pick up on the point that Senator Murray made, 
and let's be very blunt about it. We had a major problem in the 
VA before the Iraq war began. Before the Iraq war began, in my 
State and all over this country there were very long waiting 
lists for veterans to get into the VA system.
    Now, how could that be? How could people who have put their 
lives on the line defending this country have to wait month 
after month after month to get the health care that they need? 
How could it happen that the Bush Administration, in order to 
save money, would throw hundreds of thousands of Category 8 
veterans off of VA benefits entirely so that a 90-year-old 
veteran who calls my office who served in World War II cannot 
get into the VA because he is ``too wealthy,'' earning more 
than $27,000 a year?
    Mr. Chairman, let me go on record as saying that that is a 
national disgrace.
    So we start off with a VA system which is inadequate to 
deal with the veterans from World War II, Korea, and Vietnam. 
And then, lo and behold, we have the war in Iraq--22,000 
veterans are wounded, almost half of them seriously. And then 
we learn from various studies that the impact of post-traumatic 
stress disorder is going to be worse from the Iraq war than it 
was in Vietnam.
    If anybody thinks that we have the resources to adequately 
deal with veterans who are coming back from Iraq plus all of 
our older veterans, they are sorely, sorely misunderstanding 
the situation.
    And, Mr. Chairman, I hope very much and I intend to do 
everything that I can with you and with my colleagues to make 
sure that the Bush Administration, instead of giving tax breaks 
to billionaires, starts adequately funding the VA so we do not 
continue to have the disgraceful situation that we currently 
do.
    Thank you very much, Mr. Chairman.
    Chairman Akaka. Thank you, Senator Sanders.
    I would like to ask for the testimony of our witnesses, and 
I would like for our witnesses to summarize their testimony so 
that we can move on with the questions. We are delighted to 
have you here. May I first call on the Honorable Gordon H. 
Mansfield, Deputy Secretary of Veterans Affairs.

         STATEMENT OF HON. GORDON H. MANSFIELD, DEPUTY 
           SECRETARY, DEPARTMENT OF VETERANS AFFAIRS

    Mr. Mansfield. Thank you, Mr. Chairman, and thank you, 
Members of the Committee. Before I start my testimony, I would 
like to make a statement.
    When I hear words like ``misled,'' when I hear words like 
``concealed'' and words like ``failed to deliver,'' it bothers 
me not just professionally but personally. And I would make a 
commitment to this body, to the Chairman and the Members, that 
if you have information on things like this, please contact me 
and I will guarantee you that I will follow up on that and make 
sure that nobody gets misled, nothing is concealed, and that we 
do not fail to deliver on issues.
    There is no doubt in my mind what the status of this agency 
is vis-a-vis the Congress of the United States, which 
authorizes the laws that we follow up on and appropriates the 
dollars that we are given to carry out those missions, and, 
therefore, obviously, has the right for oversight and 
information. So I would just like to make that as a first 
statement, that I would commit to you that if you have 
information on that, please contact me, and I will follow up on 
it. And I will guarantee you that Secretary Nicholson feels the 
same way about these issues.
    I am pleased to be here to present testimony. I am also 
pleased to be here with Dr. David Chu, my partner in leading 
the Joint Executive Council and, in effect, getting the two 
largest bureaucracies in the United States Government--DOD and 
VA--to come together and work together. Looking back, I think I 
can truly say that we are doing a much better job of taking 
care of DOD troops who will be veterans.
    In the area of seamless transition, in the big picture we 
have moved forward in the TAP and DTAP briefing areas. We are 
also making sure that we get letters from Secretary Nicholson 
out to all servicemembers who are leaving the Service to thank 
them and give them a snapshot on what benefits they are 
entitled to, and give them information on how to proceed to get 
that. We also have people overseas, and even we have had folks 
located on Navy ships returning from deployments to give them 
briefings in an attempt to bring this information to them.
    In the smaller, more defined seamless transition area, we 
have an Office of Seamless Transition, which is really devoted 
specifically to those troops who have been severely injured and 
in military treatment facility system. We have VA social 
workers, VA benefit workers, and others on-site in MTFs like 
Walter Reed or Bethesda or around the country, and they are 
working to make sure that the transition from those facilities 
to the VA facility is handled appropriately and to make sure we 
take care of all the needs of, not only the veteran, but the 
veteran's family.
    We also have new outreach that we are doing, based on the 
fact that we have National Guard and Reserve troops coming back 
from the combat area. We now have MOUs or MOAs with the State 
Adjutant Generals to plan for and do briefings for 
servicemembers returning. And I can tell you, as I go around 
the country visiting VA regional offices where our benefits 
people are, or VA medical facilities where our health care 
providers are, I talk to our people. And everywhere I go, I 
know that these are folks who are spending weekends and nights 
going out to armories and other places in an effort to deal 
with National Guard troops and Reserve troops in an effort to 
make sure that we get them the information that they need.
    Also, we have Benefits Delivery at Discharge efforts at 
approximately 140 sites and efforts to get the departing 
servicemembers scheduled for information briefings so that they 
can get the information they need for their benefits on record 
and into the system before they leave the system. Also, we get 
the medical service records then, and we have a better chance 
of doing that, and also getting the medical exams completed so 
that we can get a decision for these folks in a reasonable time 
frame. We have also consolidated these BDD sites so that two 
sites--one at Winston-Salem and one at Salt Lake City--are 
concentrating on doing these issues.
    In the medical records area, which I know is of concern to 
the Committee, I would have to admit that there have been ups 
and downs. The latest JEC initiative from a year ago provided 
for a uniform data repository for DOD which the three services' 
medical Departments would feed into, and then VA could use that 
as a source for information we needed for either health care or 
benefits issues. I would leave the explanation of the AHLTA 
efforts that have taken place within DOD to Dr. Chu, I am sure 
he would want to talk about them.
    We also have four or five Bidirectional Health Initiative 
pilots working under the FIP program that is funded by the JEC. 
Later on today Secretary Nicholson, Secretary Leavitt, and 
Assistant Secretary Winkenwerder from DOD will be making a 
joint announcement on the most important initiative in this 
area, and that will be at the American Health Information 
Council, chaired by Secretary Leavitt, a meeting that is taking 
place at the VA today. And this will be a move toward a single-
record system which will be accessible and usable by both VA 
and DOD.
    In the JEC arena, since 2003 we have moved forward, and I 
think that we have done an excellent job in the planning arena. 
The current plan institutionalizes our collaborative efforts 
across a diverse range of health care and benefits. The broad-
based areas include clinical practice guidelines in managing 
care, and that is both DOD and VA practitioners getting 
involved to develop these guidelines; in the mental health 
arena, specifically with PTSD; patient safety practices; in 
deployment health and research; in contingency planning; in 
financial management that addresses VA and DOD billing and 
reimbursement issues; in joint facility utilization, which I 
will talk about later; information management and information 
technology; in the pharmacy area; in medical materiel 
acquisition and procurement; in VA/DOD shared high-technology 
medical contracts; in shared continuing medical education and 
training opportunities; and also in benefits delivery.
    I think one of our signature successes has been in joint 
facility utilization. For example, at the North Chicago VA 
Medical Center, which is side-by-side with the Navy training 
facility in North Chicago, there was previously a VA medical 
center and a DOD hospital right across the fence from each 
other, probably about a mile apart or half a mile apart. We 
have gone forward in a joint effort that is a pilot, and the 
final stage is that the VA medical center stays in business. We 
have added surgical suites and an emergency room to that 
facility, which is usable by both the VA community and the Navy 
community. And we are in the process of designing and building 
an outpatient ambulatory facility that we will have a 
groundbreaking for later on this spring. That ambulatory 
facility will be right next to the VA.
    Chairman Akaka. Mr. Mansfield, if you could wrap up.
    Mr. Mansfield. We will then have a functionally integrated 
Federal health care facility that will be staffed by employees 
of both agencies with a single command-and-control structure. 
In this case, we will have a VA director of the medical 
facility and a Navy director of the facility.
    The other area I want to comment on----
    Chairman Akaka. Mr. Mansfield, will you please wrap up as 
soon as you can?
    Mr. Mansfield. I will leave it there.
    Senator Rockefeller. Mr. Chairman, if I can be bold and 
slightly unkind, this is like every other presentation made by 
any Government agencies that I have ever heard in 23 years 
here. It is all cleared by OMB. You have said absolutely 
nothing, except yielding on one point where there might be a 
problem, except good news. You are telling us all the good 
things that are happening, whether they are or not, you are 
telling them to us. If you listened to us at all, we were not 
interested in that. We were interested in what is happening to 
suicides, to mental health, to PTSD, to speed of cure and care, 
and all of those things. You are simply not addressing them, 
and I would prefer that you just not finish your statement or 
that David Chu not give his statement if that is going to be 
the approach to us, because that is totally unresponsive to the 
Committee, it is totally unresponsive to the veteran, and it is 
a farce that I am long since sick of.
    Chairman Akaka. Mr. Mansfield, would you----
    Mr. Mansfield. I have completed my statement, Mr. Chairman.
    [The prepared statement of Mr. Mansfield follows:]
   Prepared Statement of Hon. Gordon H. Mansfield, Deputy Secretary, 
                     Department of Veterans Affairs
    Mr. Chairman and distinguished Members of the Committee, I am 
pleased to be here today to discuss the progress made by the Department 
of Veterans Affairs (VA) and the Department of Defense (DOD) toward 
improving the delivery of health care and benefits to our Nation's 
veterans.
    Our two Departments understand that we are responsible for the same 
people, only at different times of their lives. We agree that we must 
leverage every opportunity to improve their transition from military to 
civilian life. And, as a result, we have cemented a relationship that 
works smarter in our separate but related missions. Our reinforced 
partnership cuts across a range of difficult issues and has reduced 
many of the problems encountered by previous generations of veterans.
    I am pleased to provide an overview of the groundbreaking programs 
and pioneering initiatives VA and DOD have implemented to improve 
coordination between our two systems as we deliver our programs, 
services, and benefits.
           va/dod joint executive council and strategic plan
    First and foremost in our alliance is our Joint Executive Council 
(JEC). Established 4 years ago, the Council is the nexus for senior 
leadership management of communication, coordination, and resource 
sharing between VA and DOD. Today, the Council continues to direct 
appropriate resources and expertise to specific operational areas 
through its two sub-councils, the Health Executive Council and the 
Benefits Executive Council.
    The Council's Strategic Plan is the primary means by which we 
advance and measure our performance and our progress. It provides a 
solid framework for achieving specific goals in delivering services and 
benefits to servicemembers and veterans alike.
    The current Plan institutionalizes our collaborative efforts across 
a diverse range of health care and benefits. These broad-based areas 
include:
    (1) Clinical practice guidelines in managing care for overweight 
and obese patients;
    (2) Mental health;
    (3) Patient safety practices;
    (4) Deployment health and research, to include surveillance and 
planning activities related to depleted uranium exposure and pandemic 
flu;
    (5) Contingency planning, as outlined in a VA-DOD Memorandum of 
Understanding for health care delivery during war or national 
emergency;
    (6) Financial management that addresses VA-DOD billing and 
reimbursement issues;
    (7) Joint facility utilization;
    (8) Information management and information technology;
    (9) Pharmacy;
    (10) Medical materiel acquisition and procurement in new VA-DOD 
shared high-technology medical contracts;
    (11) Shared continuing education and training opportunities; and
    (12) Benefits delivery.
    The Strategic Plan has materially strengthened the capability of 
both Departments to better serve our beneficiaries. It fosters an 
unprecedented level of cooperation between VA and DOD as we work to 
remove institutional barriers and address operational challenges. The 
Plan represents a quantum leap in our joint ability to improve service 
and access for veterans, servicemembers, military retirees, and 
eligible dependents.
                seamless transition of care and benefits
    VA's efforts on behalf of veterans begins early on. Our Benefits at 
Discharge Program enables active duty members to register for VA health 
care and to file for benefits prior to separation from active service. 
Our outreach network ensures returning servicemembers receive full 
information about VA benefits and services. Each of our medical centers 
and benefits offices now has a point of contact assigned to work with 
veterans returning from service in Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF). Many servicemembers are enrolled in the 
VA system even before discharge.
    The staff of the Veterans Health Administration (VHA) has 
coordinated the transfer of over 6,700 injured or ill active duty 
servicemembers and veterans from DOD to VA. We hold as our highest 
priority those returning from the Global War on Terror and 
transitioning directly from DOD Military Treatment Facilities (MTFs) to 
VA Medical Centers (VAMCs).
    In partnership with DOD, VA has implemented a number of strategies 
to provide timely, appropriate, and seamless transition services to the 
most seriously injured OEF/OIF active duty servicemembers and veterans.
    VA social workers, benefits counselors, and outreach coordinators 
advise and explain the full array of VA services and benefits. These 
employees assist active duty servicemembers as they transfer to VA 
medical facilities from MTFs. In addition, our social workers help 
newly wounded soldiers, sailors, airmen and Marines and their families 
plan a future course of treatment for their injuries after they return 
home. Currently, VA Social Work and Benefit liaisons are located at 10 
MTFs, including Walter Reed Army Medical Center (WRAMC), the National 
Naval Medical Center Bethesda (NNMC), the Naval Medical Center San 
Diego, and Womack Army Medical Center at Ft. Bragg.
    A VA Certified Rehabilitation Registered Nurse (CCRN) is now 
assigned to WRAMC to assess and provide regular updates to our 
Polytrauma Rehabilitation Centers (PRC) regarding the medical condition 
of incoming patients. The CCRN advises and assists families and 
prepares active duty servicemembers for transition to VA and the 
rehabilitation phase of their recovery.
    Upon notification of the Veterans Health Administration (VHA), VA's 
Social Worker Liaisons and the CCRN fully coordinate care and 
information prior to a patient's transfer to our Department. Social 
Worker Liaisons meet with patients and/or families to advise and ``talk 
them through'' the transition process. They register servicemembers or 
enroll recently discharged veterans in the VA health care system, and 
coordinate their transfer to the most appropriate VA facility for the 
medical services needed, or to the facility closest to their home.
    In the case of polytrauma patient transfers, both the CCRN and the 
Social Worker Liaison are an integral part of the MTF treatment team. 
They simultaneously provide input into the VA health care plan and 
collaborate with both the patient and family throughout the entire 
health care transition process.
    Case management for these patients begins at the time of transition 
from the MTF and continues as their medical and psychological needs 
dictate. Once the patient transfers to the receiving VAMC, or reports 
to his or her home VAMC for care, the VA Social Worker Liaison at the 
MTF continues to coordinate with VA to address after-transfer issues of 
care. Patients suffering severe injuries, or those with complex needs, 
receive ongoing case management at the VA facility where they receive 
the predominance of their care.
    One important aspect of coordination between DOD and VA prior to a 
patient's transfer to VA is access to clinical information. This 
includes a pre-transfer review of electronic medical information via 
remote access capabilities. Video teleconference calls are routinely 
conducted between DOD MTF treatment teams and receiving VA PRC teams. 
If feasible, the patient and family attend these video teleconferences 
to participate in discussions and to ``meet'' the VA PRC team.
    The Bidirectional Health Information Exchange (BHIE) allows VA and 
DOD clinicians to share text-based clinical data in a number of sites, 
including WRAMC and NNMC, the two MTFs that refer the majority of 
polytrauma patients to VA.
    In addition to health care, Veterans Benefits Administration (VBA) 
counselors assigned to MTFs provide benefits information and assistance 
to servicemembers applying for these benefits. These counselors are 
often the first VA representatives to meet with servicemembers and 
their families and provide information about VA's full range of 
services, to include readjustment programs as well as educational and 
housing benefits.
    Counselors assist servicemembers in completing claims and in 
gathering supporting evidence. While servicemembers are hospitalized, 
they are routinely informed of the status of their pending claims and 
given their counselor's name and contact information should they have 
follow-on questions or concerns. For servicemembers who are seriously 
disabled in OEF/OIF, compensation claims are expedited to the 
appropriate VA Regional Office (VARO) with a clear indication that they 
involve OEF/OIF claimants.
    For a period of 2 years following separation from active duty, all 
veterans who served in combat locations are eligible for free health 
care services for conditions potentially related to combat service. 
These veterans can access VA health care, even those who have no 
service-connected disability. Veterans who enroll continue to be 
eligible for medical care after this 2-year window. This enrollment 
``window'' applies to regular active-duty personnel who served in Iraq 
or Afghanistan, as well as Reserve or National Guard members who served 
in combat theaters.
    Each VAMC and VARO has a designated point of contact (POC) to 
coordinate activities locally and to ensure the health care and 
benefits needs of returning servicemembers and veterans are fully met. 
VA has distributed specific guidance to field staff to ensure that the 
roles and functions of the POCs and case managers are fully understood, 
and that proper coordination of benefits and services occurs at the 
local level.
    In March 2005, the Army assigned full time active duty liaison 
officers to VA's four Polytrauma Rehabilitation Centers located at 
Tampa, FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. The Army 
Liaison Officers support military personnel and their families from all 
Service branches by addressing a broad array of issues, such as travel, 
housing, military pay, and movement of household goods.
    In addition, Marine Corps representatives from nearby local 
Commands visit and provide support to each of the Polytrauma 
Rehabilitation Centers. At VA Central Office in Washington, DC, an 
active duty Marine Officer and an Army Wounded Warrior representative 
are assigned to the Office of Seamless Transition. All DOD liaisons 
play a vital role in providing a wide bridge of services during the 
critical time of patient recovery and rehabilitation.
    VA understands the critical importance of supporting families 
during the tumultuous time of transition. We established a Polytrauma 
Call Center to assist the families of our most seriously injured combat 
veterans and servicemembers. Initiated in February 2006, the Call 
Center operates 24 hours-a-day, 7 days-a-week to answer clinical, 
administrative, and benefit inquiries from polytrauma patients and 
family members. The Center's value is threefold. It furnishes patients 
and their families with a one-stop source of information; it enhances 
overall coordination of care; and, very importantly, it immediately 
elevates any system problems to VA for resolution.
    VA's mission is to deliver 21st century care to 21st century combat 
veterans. We are meeting our mandate through the life-saving and life-
shaping medicine in our health care arsenal.
                              va outreach
Office of Seamless Transition
    The Office of Seamless Transition is the lynchpin in VA's outreach 
efforts. Two Outreach Coordinators one a peer-support volunteer and a 
veteran of the Vietnam War regularly visit seriously injured 
servicemembers at WRAMC and NNMC Bethesda. Their visits have 
established a uniquely personal and trusted connection with patients 
and their families. Our Outreach Coordinators offer support and 
encouragement as patients travel the often ``rough and tough'' roads of 
rehabilitation. These individuals help identify gaps in VA services by 
submitting and tracking follow-up recommendations. They encourage 
patients to consider participating in VA's National Rehabilitation 
Special Events or to attend weekly dinners held in Washington, DC, for 
injured OEF/OIF returnees. They are first-responders in helping our 
injured servicemembers come to a renewed belief in themselves and in 
their future. In short, they are key to enhancing and advancing the 
successful transition of our service personnel from DOD to VA, and, in 
turn, to their homes and communities.
The National Guard and Reserve
    VA has developed a vigorous outreach, education, and awareness 
program for the National Guard and Reserve. To ensure coordinated 
transition services and benefits, a Memorandum of Agreement (MOA) was 
signed with the National Guard in May 2005. Combined with VA/National 
Guard State Coalitions in 54 states and territories, VA has 
significantly improved its opportunities to access returning troops and 
their families. We are continuing to partner with community 
organizations and other local resources to enhance the delivery of VA 
services.
    At the national level, MOAs are under development with both the 
United States Army Reserve and the United States Marine Corps. These 
new partnerships will increase awareness of, and access to, VA services 
and benefits during the demobilization process and as service personnel 
return to their local communities.
Post Deployment Health Reassessment
    VA is also reaching out to returning veterans whose wounds may be 
less apparent. VA is a participant in the DOD's Post Deployment Health 
Reassessment (PDHRA) program. In addition to DOD's pre- and post-
deployment assessments, DOD now conducts a health reassessment 90-180 
days after return from deployment to identify health issues that can 
surface weeks or months after servicemembers return home.
    VA actively participates in the administration of PDHRA at Reserve 
and Guard locations in a number of ways. We provide information about 
VA care and benefits; enroll interested Reservists and Guardsmen in the 
VA health care system; and arrange appointments for referred 
servicemembers. As of December 2006, an estimated 52,000 servicemembers 
were screened, resulting in over 13,900 referrals to VA. Of those 
referrals, 32.5 percent were for mental health and readjustment issues; 
the remaining 67.5 percent for physical health issues.
Outreach Readjustment Counseling
    Congress created the Readjustment Counseling Service (RCS), 
commonly known to veterans as the Vet Center Program, as the outreach 
element in VA's Veterans Health Administration. Program eligibility was 
originally targeted to Vietnam veterans; however, it now serves all 
returning combat veterans. The program is the undisputed ``gold 
standard'' in veterans' satisfaction (98 percent), employee 
satisfaction, and across other measurable indicators of quality and 
effective care.
    The program helped form the basis for the President's New Freedom 
Commission on Mental Health. It is recognized as a National model for 
outreach and readjustment services, and emulated by other countries in 
their efforts to ease the readjustment of combat veterans to civilian 
life.
    The approximate number of OEF/OIF combat veterans served by Vet 
Centers to date is 180,000. The Secretary of Veterans Affairs approved 
the hire of 100 additional OEF/OIF combat veterans to support the 
Program by reaching out to active, National Guard, and Reserve veterans 
returning from Southwest Asia. This single action advanced the 
continuing success of our Vet Centers in their ability to assist our 
newest veterans and their families. VA Vet Centers have provided 
bereavement services to the families of over 900 fallen warriors.
    VA plans to expand its Vet Center Program. We will open 15 new Vet 
Centers and 8 new Vet Center outstations at locations throughout the 
Nation by the end of 2008. At that time, Vet Centers will total 232. We 
expect to add staff to 61 existing facilities to augment the services 
they provide. Seven of the 23 new centers will open during Calendar 
Year 2007.
                   polytrauma/traumatic brain injury
VA Clinical Reminders for Mild Traumatic Brain Injury (TBI)
    Veterans and active duty servicemembers with TBI recognized at the 
time of injury receive state-of-the-art, highly specialized care at 
both DOD and VA TBI Centers. However, less severe injuries may not 
become evident until military personnel return home to the care of 
their community physicians, DOD, or VA medical centers. Prompt 
diagnosis is often complicated by the fact that many who sustain mild 
brain injury do not recall the trauma that caused it. As a result, some 
patients with symptoms seemingly unrelated to mild TBI, such as 
headaches, sleep disturbances and depression, may go undiagnosed.
    To assist clinicians in the diagnosis of mild TBI, the VA Chief of 
Patient Care Services stood up the Traumatic Brain Injury Clinical 
Reminder Work Group to develop clinical reminders to identify possible 
TBI in OEF/OIF veterans.
    Membership is multidisciplinary and includes representatives from 
physical medicine and rehabilitation services, mental health, primary 
care, neurology, information technology, occupational and environmental 
health, as well as operations and management. The project's scope 
encompasses development of a screening instrument, appropriate follow-
up for potential positive screens, and integration with VHA Health 
Information Systems to support system-wide implementation.
TBI Education
    To ensure that all VA health care providers are well prepared to 
recognize brain injury sequelae, clinical management, and treatment 
approaches, VA's Under Secretary for Health has mandated a 4-hour 
continuing education course on Traumatic Brain Injury, to be completed 
by March 31, 2007.
VA/DOD Memorandum of Agreement
    VA and DOD have in operation a longstanding MOA regarding referral 
of active duty military personnel who sustain spinal cord injury, TBI, 
or blindness to VA medical facilities for health care and 
rehabilitation. The MOA facilitates transfer of personnel to VA 
facilities that specialize in care and rehabilitation of these 
conditions. Effective January 1, 2007, the Assistant Secretary for 
Health Affairs, Department of Defense and the Acting Under Secretary 
for Health, Department of Veterans Affairs, renewed this MOA in support 
of VA/DOD resource sharing.
                          mental health issues
    In Fiscal Years (FY) 2005 and 2006, VA increased funding of new and 
enhanced mental health programs for OEF/OIF veterans and others with 
Post Traumatic Stress Disorder (PTSD). VA will do so again in Fiscal 
Year 2007 to better meet the clinical needs of all veterans.
    Additional funding initiatives are targeted to increase the mental 
health capacities of Community Based Outpatient Clinics and enhance 
telemental health capabilities in rural areas. VA's goal is to make 
mental health services more accessible for all we serve.
    In Fiscal Year 2007, VA will fund enhanced integration of Mental 
Health and Primary Care services to increase our ability to provide 
veterans with comprehensive health care. Given the possible reluctance 
of some veterans to disclose emotional problems, increased mental 
health capacity in primary care will allow veterans to receive mental 
health services without actually going to an identified mental health 
clinic.
    In Fiscal Year 2006, under the auspices of specialized and general 
mental health programs, VA treated 345,713 veterans with a clinical 
diagnosis of PTSD. This represents an increase of 27,099 individuals 
over Fiscal Year 2005. Of those treated in Fiscal Year 2006, 241,884 
(70 percent) had a primary diagnosis of PTSD.
    VA's health care system features more than 200 specialized VAMC-
based PTSD programs. Every VA medical center now has specialty PTSD 
capability. There are over 80 VAMC-based OEF/OIF programs operating in 
collaboration with specialized PTSD programs, general mental health 
clinics, and primary care facilities. Staff training to support these 
programs has been developed in collaboration with DOD counterparts at 
the U.S. Army and U.S. Marine Corps.
    Since the beginning of the OEF/OIF conflict, VA medical centers 
have seen nearly 34,000 veterans with a possible diagnosis of PTSD, 
i.e., veterans who received a PTSD diagnosis from a health care 
provider on at least one occasion. There has been an increase of 17,827 
new provisional diagnoses of PTSD in Fiscal Year 2006.
    Since hostilities began, more than 23,000 veterans received a 
provisional diagnosis of a depressive disorder, and 7,800 were 
provisionally diagnosed with alcohol or drug dependence.
                       va/dod information sharing
    VA and DOD have made significant progress in the development of 
interoperable health technologies that support seamless transition from 
active duty to veteran status. Advances include the successful one-way 
and bidirectional transmission of electronic medical records between 
DOD and VA, and the adoption and implementation of data standards which 
support interoperability.
    VA and DOD information sharing successes have resulted directly 
from implementation of the DOD/VA Joint Electronic Health Records 
Interoperability (JEHRI) Plan. JEHRI is a comprehensive strategy to 
develop collaborative technologies and interoperable data repositories, 
as well as adoption of common data standards.
    The DOD/VA Health Executive Council, co-chaired by VA's Under 
Secretary for Health and DOD's Assistant Secretary of Defense for 
Health Affairs, manages the day-to-day implementation activities of 
JEHRI.
    DOD and VA began implementation of the JEHRI Plan in 2002 with 
successful execution of the Federal Health Information Exchange (FHIE). 
Since then, FHIE has supported the secure one-way transmission of DOD 
electronic medical records to a shared repository, where records reside 
for review by clinicians treating veterans at VA hospitals and clinics. 
These same records are also available to VA claims examiners, who 
access FHIE data through an interface with the VBA Compensation and 
Pension Records Interchange (CAPRI). VA presently has access to FHIE 
data for more than 3.6 million unique beneficiaries.
    FHIE also supports the one-way transmission of pre- and post-
deployment health assessment data from DOD to VA. The Departments have 
recently begun the transmission and viewing of post-deployment health 
reassessments (PDHRA) to (1) monitor the overall health condition of 
troops; (2) inform them of potential health risks; and (3) work to 
benefit the overall health of servicemembers and veterans.
    In 2004, VA and DOD leveraged FHIE technologies to develop the 
capability to support the real-time bidirectional exchange of 
electronic medical records. By using the Bidirectional Health 
Information Exchange, VA and DOD clinicians share text-based clinical 
data between medical facilities where patients (who receive care from 
both systems) are seen. BHIE also supports the real-time bidirectional 
exchange of outpatient pharmacy data, anatomic pathology/surgical 
reports, cytology results, microbiology results, chemistry and 
hematology laboratory results, laboratory order information, radiology 
text reports, and food and drug allergy information.
    BHIE data from every VA site are available at select DOD sites 
where BHIE is installed. DOD is continuing to install BHIE, and system 
implementation has been completed at 21 major sites. These include 
facilities where large numbers of OEF/OIF servicemembers are seen, such 
as Walter Reed Army Medical Center and the National Naval Medical 
Center Bethesda, the Landstuhl Regional Medical Center in Germany, and 
the Naval Medical Center San Diego.
    As mentioned, JEHRI is a comprehensive strategy for sharing data. 
Where BHIE supports the bidirectional sharing of health data between 
legacy systems, JEHRI takes into account that both DOD and VA are 
modernizing their health information systems. The next phase of JEHRI, 
the Clinical Health Data Repository (CHDR), provides a means for VA and 
DOD to develop an interface between the DOD Clinical Data Repository 
(CDR) of DOD's AHLTA system and the VA Health Data Repository (HDR) of 
the next-generation VistA system, known as HealtheVet.
    Through CHDR, DOD and VA have the groundbreaking ability to share 
computable data between next-generation systems featuring automatic 
decision support for clinicians, e.g., drug-drug and drug-allergy 
interaction checks. DOD and VA currently use this interface between the 
William Beaumont Army Medical Center and the El Paso VA Healthcare 
System to support care of shared patients as well as at Augusta, 
Georgia, and Pensacola, Florida, locations. VA and DOD are working to 
expand the types of clinical data available through CHDR, specifically 
laboratory data.
    Our Departments are also collaborating on an interface between CHDR 
and BHIE to accelerate bidirectional data sharing and make it available 
at all sites of care, not solely at select DOD BHIE sites. The CHDR-
BHIE Interface will make the same data elements currently in BHIE 
available to VA from all 138 DOD locations where AHLTA and the CDR are 
deployed. VA and DOD also are planning to make additional data from 
AHLTA available to VA, such as provider notes, procedures, and problem 
lists.
    In addition to FHIE, BHIE and CHDR, VA and DOD have successfully 
developed a number of other applications that support information 
sharing, improve care, and support seamless transition. For example, 
the jointly developed Laboratory Data Sharing Interoperability (LDSI) 
software permits VA and DOD to serve as reference laboratories for one 
another. This typically occurs at locations where VA and DOD use each 
other's facilities to order and conduct chemistry laboratory tests and 
results reporting.
    Our two Departments are also working to expand VA access to DOD 
inpatient documentation, particularly for severely wounded and injured 
servicemembers being transferred to VA for care. An early version of 
this electronic capability is currently in use between Madigan Army 
Medical Center and the VA Puget Sound Health Care System, where 
inpatient discharge summaries are exchanged.
    The Departments also are cooperating to modernize imaging systems 
using shared technologies and to transfer improved scanned images of 
paper-based medical records. Both these efforts will help to ensure VA 
has access to significant inpatient data, especially for severely 
injured servicemembers about to transfer to VA for care and treatment.
    VA has been widely recognized for its outstanding electronic health 
record. With this sharing of expertise, the two Departments will work 
on this initiative to benefit servicemembers and veterans, and the 
entire Nation as we move toward electronic medical records.
    VistA, the VA electronic health record, supports ambulatory care 
plus a segmentable but integrated inpatient care capability. VA is 
planning to modernize VistA, including its inpatient module. We believe 
that this is an opportunity to explore a ``born seamless'' approach for 
a joint inpatient electronic health record.
    It is likely that much of DOD and VA inpatient healthcare data, 
processes and requirements are similar. But there are some known 
differences. For example, the VA has no requirement for theater 
inpatient care and DOD does not provide long-term domiciliary care.
    The analysis will identify the areas of commonality and the areas 
of uniqueness. This project will document and assess DOD and VA 
inpatient clinical processes, workflows, and requirements, determine 
the benefits and impacts on each Department's timelines and costs for 
deploying a common inpatient electronic health record solution and 
develop the business case analysis for alternative approaches.
Center for the Intrepid: The National Armed Forces Physical 
        Rehabilitation Center
    For the past year, the Department has been actively engaged with 
the Department of the Army and the Intrepid Fallen Heroes Foundation on 
operational plans for the Center for the Intrepid--a 65,000 square 
foot, state-of-the-art rehabilitation facility at Brooke Army Medical 
Center, Fort Sam Houston.
    When the Center is dedicated on January 29, 2007, seven VHA and two 
VBA staff members will be working side-by-side with Army colleagues to 
provide the best possible rehabilitative services to severely injured 
servicemembers and veterans. VHA will provide physical therapy, 
occupational therapy, prosthetics services, social work case 
management, and seamless transition liaison services. VBA will offer 
information and education about benefits and vocational rehabilitation 
services, and provide assistance with benefits claims.
    We envision that the Center will provide educational and research 
opportunities that will better prepare VA staff for assisting our 
Nation's newest generation of veterans.
The North Chicago VA Medical Center/Naval Health Clinic Great Lakes 
        Initiative
    On October 17, 2005, I co-signed an MOA with the Assistant 
Secretary of Defense for Health Affairs that represents a historic 
collaboration between VA and DOD. Our joint effort ``raises the bar'' 
in standards of economy, efficiency, and management. The North Chicago 
VA Medical Center (NCVAMC) and the Naval Hospital Great Lakes are fully 
sharing all health services in one facility at North Chicago to provide 
all needed care to each other's beneficiaries.
    The North Chicago initiative called for full modernization of 
NCVAMC's surgical and emergency/urgent care facilities and for VA to 
provide health care services to the Navy's beneficiary population 
treated at Great Lakes. The Naval Hospital Great Lakes was re-
commissioned as the Naval Health Clinic Great Lakes. In 2006, NCVAMC 
began providing the Navy's beneficiary population in that area all of 
its emergency, surgical, and inpatient care.
    The scheduled groundbreaking ceremony for the Federal Ambulatory 
Care Center is Spring 2007. Our working groups are continuing to 
develop detailed operational plans for its activation in 2010.
                                closing
    Mr. Chairman, I believe our efforts and progress speak to a new era 
of cooperation between the Department of Veterans Affairs and the 
Department of Defense. The strides we have made toward transparent and 
seamless transition have been recognized by both the Inspector General 
and the Government Accountability Office.
    We have forged new ties and cast a revitalized, more productive 
relationship. We are working smarter to carry out our separate but 
related missions. We are better coordinating our overlapping 
infrastructure and services. We are striving to ensure more efficient 
use of taxpayer dollars. And we are continuing to seek out potential 
opportunities for partnership.
    Our Departments are singularly committed to the men and women we 
both serve. They are our highest priority.
    President Lincoln once said, ``The struggle of today is not 
altogether for today it is for a vast future also.''
    Our greatest challenge, and our greatest opportunity, is to build 
systems that meet the needs of veterans and DOD beneficiaries for today 
and tomorrow. We will continue to persevere toward that goal.
    Mr. Chairman, this concludes my statement. I thank you and Members 
of this Committee for your outstanding and continued support of our 
servicemembers, veterans, and their families.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Daniel K. Akaka
    Question 1.  In July 2006, the VA Office of the Inspector General 
(OIG) issued a report on the ``Health Status of and Services for 
Operation Enduring Freedom/Operation Iraqi Freedom Veterans After 
Traumatic Brain Injury Rehabilitation.'' The VA OIG identified problems 
with respect to VA and DOD coordination and collaboration that impacted 
the timeliness and access to rehabilitative services for servicemembers 
with TBI who remain on active duty status after completing their 
inpatient rehabilitative care at VA. What is VA doing to improve case 
management for veterans with traumatic brain injuries?
    Response: Case management is a critical function designed to ensure 
lifelong coordination of services for patients with polytrauma and 
traumatic brain injury (TBI), and is an integral part of the system at 
each polytrauma care site. The polytrauma system of care (PSC) uses a 
proactive case management model, which requires maintaining routine 
contacts with veterans and their families to coordinate services and to 
address emerging needs. As an individual moves from one level of care 
to another, the case manager at the referring facility is responsible 
for a ``warm hand off'' of care to the case manager at the receiving 
facility closer to the veteran's home. The assigned case manager 
handles the continuum of care and care coordination, acts as the point 
of contact for emerging medical, psychosocial, or rehabilitation 
problems, and provides patient and family advocacy.
    A polytrauma telehealth network has been established linking the 
four regional TBI/polytrauma rehabilitation centers and their 
respective network sites. This technology is an additional resource to 
the Department of Veterans Affairs (VA) TBI/polytrauma clinicians for 
patient care coordination and family support closer to home.
    VHA is currently recruiting to hire 100 new transition patient 
advocates to assist severely injured Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) veterans. These new transition 
patient advocates will serve as the liaison for veterans and their 
families, helping them to communicate their needs to the VHA health 
care team and addressing their problems and concerns. Each transition 
patient advocate will be assigned to work with 25-30 severely injured 
OEF/OIF veterans and will follow those veterans across episodes and 
sites of care, beginning at the point their care is transitioned from 
the Military Treatment Facility to a VHA health care facility. 
Transition patient advocates will work collaboratively with the 
veteran's health care team, particularly with the nurse and social 
worker case managers. VHA anticipates filling these positions 
expeditiously.

    Question 2. I am encouraged by VA's implementation of its Seamless 
Transition Performance Measure, which monitors the transfer of injured 
veterans from DOD to VA facilities. As I understand it, this measure 
was fully implemented in early October 2006. What can you report as to 
its effectiveness? As a percentage, how many veterans are being 
contacted by a VA case manager within 7 days of VA receiving 
notification of their transfer from DOD?
    Response: In October 2006, VA implemented a seamless transition 
performance measure to ensure that every severely ill/injured 
servicemember or veteran who is transferred from a Department of 
Defense (DOD) military treatment facility (MTF) to any VA healthcare 
facility has a case manager assigned to him or her at the receiving 
facility before arriving at that facility. The receiving facility has 7 
calendar days after notification of transfer in which to assign a case 
manager to the servicemember or veteran and to call him or her to 
facilitate the transfer. Between October 10, 2006 and January 17, 2007, 
72 severely ill or injured patients were transferred from DOD MTFs to 
VA healthcare facilities. During this time period, 65 (90.3 percent) of 
these patients were assigned a VA case manager within the 7 day 
standard. For the 7 cases that did not meet the performance measure, 3 
exceeded the 7-day time frame to contact the patients but case managers 
have been assigned. For the other 4 patients, case managers have also 
been assigned but have been unable to contact the patients.

    Question 3. To what extent have efforts been made to coordinate 
with the Department of Labor to assist returning servicemembers in 
finding meaningful employment in a timely fashion? What employment 
related efforts have VA made on its own accord?
    Response: VA's Vocational Rehabilitation & Employment (VR&E) 
service and the Department of Labor's Veterans' Employment and Training 
Service (VETS) updated their existing memorandum of understanding (MOU) 
in October of 2005. VR&E and VETS adopted a team approach to job 
development and placement activities to improve vocational outcomes for 
vocational rehabilitation program participants. All veterans entering a 
program of vocational rehabilitation are informed of the employment 
assistance available through the VETS program and are encouraged to 
register with the State workforce agency.
    The successful readjustment of disabled veterans into the civilian 
workforce is the mutual responsibility and concern of VA's VR&E service 
and the Department of Labor, VETS. Combining the services of the 
disabled veteran outreach program (DVOP) specialists, local veteran's 
employment representatives (LVER), and VR&E staff maximizes the 
employment services available to disabled veterans and increases the 
opportunities for successful placements. Both agencies are committed to 
working together to improve successful employment outcomes for our 
Nation's veterans.
    Regional offices (RO) have MOUs with their State workforce 
agencies, which define their referral processes. Generally, the VR&E 
counselor provides a personal introduction to the veteran when the DVOP 
specialist/LVER is co-located with the VR&E. A referral form is 
completed and forwarded to the DVOP specialist/LVER when the DVOP 
specialist/LVER is not co-located.
    There are 71 DVOP specialists/LVERs at 38 VA offices. Having the 
DVOP specialist/LVER onsite enhances the teamwork between the two 
agencies. Whether a DVOP specialist/LVER is co-located at a VR&E or 
not, these VETS employees assist VR&E staff with the following tasks:

    (1) Participate in the orientation to the VR&E program.
    (2) Provide initial labor market information during evaluation and 
planning phase.
    (3) Provide ``survival employment'' (not necessarily ``suitable 
employment'') to the veteran to supplement finances while the veteran 
is receiving training/vocational services under the VR&E program.
    (4) Monitor/staff the job resource labs and assist veterans with 
job seeking activities.
    (5) Assist with locating supportive services (human service 
organizations) in the community when assistance outside the parameters 
of the VR&E program is needed.
    (6) Assist veterans in obtaining and maintaining employment by 
providing job development and placement services.
    (7) Serve as a referral source for employment services when a 
veteran is not eligible for the VR&E program.
    (8) Provide wage information and placement data.

    VA's VR&E program provides veterans with service-connected 
disabilities a wide range of employment assistance including, formal 
education needed for employment, on-the-job training, apprenticeships, 
and internships to meet their individual career goals. VR&E implemented 
the Five Tracks to Employment Process, which includes job resource 
labs, Web-based information resources (http;//www.VetSuccess.qov) and a 
standardized orientation. VR&E also stationed 72 employment 
coordinators (ECs) at ROs across the country. The primary function of 
the EC is to provide veterans with disabilities any necessary job 
readiness skills prior to and including job referral/placement. This 
network of ECs works closely with local employment resources, including 
the DVOP specialists and LVERs at the State workforce agencies. The ECs 
also support the Five Tracks to Employment Process.
    VR&E service continually seeks out and initiates new partnerships 
with employers and education/training institutions to meet the needs of 
injured returning servicemembers. Some of the recent initiatives 
launched by VR&E to meet the unique employment and rehabilitation needs 
of returning servicemembers are:

     Faith-based community initiative (FBCI), which focuses on 
improving veterans' employment opportunities in the nonprofit sector.
     Lockheed Martin's new supply chain management 
apprenticeship program.
     Federal Aviation Administration's (FAA) new agreement to 
train veterans at the FAA Academy in air traffic control and as airway 
facilities specialists.
     Federal non-paid work experience (NPWE) programs with 
Federal, State, and local government agencies as part of the coming 
home to work program.
     Veterans Health Administration's (VHA) prosthetic 
representative trainee program.
     Improvements to the early outreach effort by VA to inform 
veterans/servicemembers of their VA benefits.

    Question 4. VA is in the process of moving from a decentralized to 
a centralized organizational structure for its Information Technology 
Program with IT funding and responsibility for systems development 
moving to the Department's Chief Information Officer. Has the 
realignment impacted the initiative to develop the interface between VA 
and DOD's health data repositories?
    Response: Centralization of information technology (IT) authority 
under the Chief Information Officer will enhance significantly the 
ability of the Department to advance VA-DOD collaboration. With the 
central authority, VA can now assure that resources and schedules are 
coordinated among all stakeholders so that there is an even stronger 
programmatic foundation for interdepartmental collaboration for IT 
initiatives.
    The VA CIO is committed to advancing VA-DOD collaboration; is 
aligned with VA strategic plan as well as VA-DOD Joint strategic plan; 
and supports both information interoperability to enhance service to 
veterans and joint development initiatives to reduce cost and time to 
market for new IT products.

    Question 5. What measures does VA have in place to protect the 
personally identifiable information that is being maintained in its 
health data repository and how is VA securing the transfer of 
personally identifiable information to DOD?
    Response: Personally identifiable information maintained in the 
health data repository (HDR) is controlled through the standard 
Veterans health information systems and technology architecture (VistA) 
legacy security controls, which includes authentication using standard 
access and verification codes, and user access is controlled using 
Kernel security's option and menu management and security keys. HDR 
completed certification and accreditation requirements per National 
Institute of Standards and Technology (NIST) and received authority to 
operate in August 2006.
    HDR does not transfer any data to DOD; that is accomplished through 
the Clinical/Health Data Repository (CHDR) system. Medical information 
data exchange for patients that are using both VA and DOD health care 
is done via machine-to-machine exchange, which does not involve end 
users. Data transmission is accomplished using a virtual private 
network (VPN) two-way communication channel that is compliant with DOD 
security standards.

    Question 6. The 2003 Presidential Task Force to Improve Health Care 
Delivery for Our Nation's Veterans (PTF) recommended that the 
Administration direct HHS to declare the two Departments to be a single 
health care system for purposes of implementing HIPAA regulations. How 
did VA and DOD respond to the recommendation? How have the HIPAA 
requirements impacted your health information exchange efforts?
    Response: VA's response to the President's Task Force (PTF) to 
Improve Health Care Delivery of Our Nation's Veterans indicated VA's 
agreement with the intentions of reducing data sharing impediments 
between the agencies. VA, however, maintained its belief that there are 
sufficient authorities within the Health Insurance Portability and 
Accountability Act (HIPAA) legislation to allow sharing of protected 
health information without becoming one single entity.
    In general, the HIPAA privacy final rule prohibits the 
nonconsensual disclosure of protected health information (PHI). This 
rule, however, includes a special exemption pertaining to DOD's sharing 
data with VA. This exception, 45CFR 164.512(k)(1)(ii), allows DOD to 
``disclose to Department of Veterans Affairs (DVA) the protected health 
information of an individual who is a member of the Armed Forces upon 
the separation or discharge of the individual from military service for 
the purpose of a determination by DVA of the individual's eligibility 
for or entitlement to benefits under laws administered by the Secretary 
of Veterans Affairs.'' In addition, there are several other authorities 
provided in the privacy rule that allow DOD and VA to share IIHI, 
including treatment purposes for which no patient authorization is 
required, pursuant to a signed authorization from the patient and other 
authorities that allow the covered functions in both organizations to 
share PHI for various other purposes. VA and DOD HIPAA, privacy and 
general counsel staffs worked diligently to resolve any differences in 
interpretation of these authorities. In the end, DOD and VA were able 
to implement a data-sharing MOU that outlines these agreed-upon 
authorities.
    The HIPAA privacy rule has not impacted VA's health information 
exchange efforts as ample authority exists under this rule for the 
exchange of health information both with DOD and private and public 
health care providers.

    Question 7. I understand that VA maintains eight full-time and two 
part-time VA/DOD liaison positions at DOD hospitals. How were the DOD 
facilities selected and does VA plan to expand this program in Fiscal 
Year 2007 and beyond?
    Response: VA currently has nine full-time and three part-time VA/
DOD Liaisons stationed at 10 MTFs located throughout the United States. 
Two new sites were added in 2006--Naval Medical Center, San Diego and 
Womack Army Medical Center, Fort Bragg, NC. DOD facilities were 
selected based on their workload of returning Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. VA continues to 
monitor the volume of returning veterans and will expand the program as 
needed.

    Question 8. In 2003, the PTF recommended that, there should be a 
mandatory physical exam for all separating servicemembers. I understand 
that currently a separation physical is only mandatory for those who 
are retiring. Do you believe that a separation physical should be 
mandatory for all personnel leaving the military?
    Response: We defer to DOD for details on their requirements of 
physical examinations for all separating servicemembers; however, we 
understand that all active duty members are provided with periodic 
health assessments. Individuals retiring from active duty or those 
returning from deployment and leaving service receive separation 
physicals. All other separating members are given a health screening 
questionnaire to determine whether a follow-up assessment is needed.

    Question 9. For VA and DOD, the Joint Executive Council Strategic 
Plan is the primary way by which you advance and measure performance 
and progress. What specific measures are in place to evaluate the 
effectiveness of your efforts?
    Response: The VA/DOD Joint Strategic Plan for Fiscal Year (FY) 
2007-2009 has 34 specific performance measures in place to evaluate the 
effectiveness of the Joint Executive Council (JEC). Measures are linked 
to six broad goals:

    (1) Leadership commitment and accountability;
    (2) High quality health care;
    (3) Seamless coordination of benefits;
    (4) Integrated information sharing;
    (5) Efficiency of operations; and
    (6) Joint medical contingency/readiness capabilities.

    While some measures are single event milestones, 17 are outcome 
measures designed to promote progress over time. Future strategic plans 
will include mostly outcome oriented measures.
    Two examples of performance outcome measures in the current Joint 
Strategic Plan are provided for the Health Executive and the Benefits 
Executive Councils (HEC/BEC).

    1. HEC, Graduate Medical Education Working Group, will examine 
opportunities for greater VA/DOD collaboration and with implementation 
of four initiatives the expected result will lead to a 50 percent 
increase in the number of military trainees applying for positions in 
VA-affiliated residency programs within 2 years.
    2. BEC will oversee an increase in the percent of original claims 
filed within the first year of release from active duty at a BDD site 
(prior to a servicemembers discharge) achieving 57 percent in Fiscal 
Year 2007; 61 percent in Fiscal Year 2008; and 66 percent in Fiscal 
Year 2009.

    Progress is monitored at quarterly meetings of the JEC. Results 
achieved are presented in the JEC Annual Report to Congress.
    The President's Management Agenda is a joint initiative that is 
focused on activities intended to institutionalize increased sharing 
and coordination between DOD and VA. The Proud To Be (PTB) and 
President's Management Scorecard are a focused subset of initiatives 
that are managed through the Joint Executive Council (JEC). OMB 
provides oversight for the PTB and scorecard documents.
    Specifically, the PTB has identified two strategic areas of focus 
intended to indicate the institutionalization of processes related to 
information technology (IT) and process changes to overcome technical 
and administrative barriers.
    The specific strategic areas in each subset are:
    1. Use of Information Technology to Institutionalize Processes
Health IT
    1. Real-Time Bi-Directional Electronic Patient Medical Records
    2. Consolidated Health Informatics
Benefits IT
    1. VA/DOD Military Personnel Data Sharing
    2. Process Changes to Overcome Administrative Barriers.
Structure
    1. Establish National Defense Authorization Act 2003 Pilot Projects
    2. Cooperative Separation Process/Exam
People
    1. Develop Joint Graduate Medical Education (GME) Pilot Program
    2. Increase non-GME Training and Education Sharing
Procurement
    1. Joint Purchasing of Non-Drug Medical Supplies and Equipment

    Question 10. I understand that VA's Overseas Military Services 
Coordinators are only available in Europe for 9 months a year and that 
they are stretched too thin, with only 2 persons covering all of Europe 
at any given time. Is this a function of funding or a perceived lack of 
need, and what can be done to improve overseas transition assistance?
    Response: VA's overseas military services program was implemented 
in 1994 under a memorandum of agreement with DOD. Under this agreement, 
VA provides overseas military service coordinators, and DOD provides 
logistical support and travel funding. Since the beginning of the 
program, coverage has been less than 12 months; however, VA is 
extending this coverage in Fiscal Year 2008. Beginning Fiscal Year 
2007, VA will be funding the travel cost for the program, estimated at 
$489,000 for Fiscal Year 2007.
    The number of coordinators serving overseas has continued to 
increase. During Fiscal Year 2006, 7 coordinators were assigned to 
Europe and Asia for 9 months. In addition, Korea is covered on a full-
time basis by veterans service representatives assigned to our BDD site 
at Yongsan Army Base. Approximately 500 benefits briefings were 
conducted by our overseas coordinators and attended by about 12,000 
active duty personnel and family members. The coordinators personally 
interviewed over 3,000 individuals in conjunction with these briefings. 
Seven overseas coordinators will provide services from mid-January 
until the end of September 2007, and will be assigned as follows: two 
in Germany, who also serve Belgium and the Netherlands; one in England, 
who also serves Bahrain; one in Italy, who also serves Spain and 
Portugal; two in Japan; and one in Okinawa. VA benefits briefings will 
be conducted at about 70 overseas military facilities.
    Effective in Fiscal Year 2008, VA will provide coverage 12 months a 
year with 7 counselors covering the locations outlined above.

    Question 11. In September 2005, DOD issued a policy memo to the 
Services Secretaries directing them to provide VA with the names of 
servicemembers entering DOD's Physical Evaluation Board process. I 
understand that in May 2006, this initiative was put on hold because of 
DOD concerns about data security compliance. Why was the initiative put 
on hold and what is its current status? Are there any issues related to 
the May 2006 VA data theft that have affected VA's and DOD's ability to 
share data?
    Response: From October 2005 through May 2006, DOD was e-mailing a 
list of servicemembers entering DOD's physical evaluation board (PEB) 
process via a password-protected Excel spreadsheet. In May 2006, VA 
asked DOD to cease sending the list in this manner, as it didn't meet 
VA's heightened security requirements. Transmission of the data was 
halted until VA and DOD could implement a secure method of transmitting 
the data between Departments. Currently VA and DOD are evaluating 
transmitting the data electronically via a Federal Information 
Processing Standards (FIPS) 140-2 compliant secure file transfer 
protocol (FTP) server or one of the existing VA/DOD data feeds, such as 
the Federal Health Information Exchange (FHIE).
    Additional factors have delayed the use of the PEB data. In 
conjunction with addressing the secure transfer, VA staff has been 
addressing PEB file quality issues that vary widely with each file and 
are therefore, difficult to mitigate. Further, the VA data incident in 
May 2006 created significant delays and disruption in the data exchange 
and process.
    DOD has suggested that they will seek a way to automate the 
collection of the PEB list. DOD made extra efforts to make this data 
available to VA for outreach; however, due to the issues noted, the use 
has been limited thus far.

    Question 12. In May 2005, VA and the National Guard signed a 
memorandum of agreement that formalized a partnership between the 
National Guard Bureau and VA to enhance the ability for VA to have 
access to troops, and brief returning servicemembers and their family 
members. Please describe the impact of this agreement. Also, please 
describe how VA is working with the other Reserve components.
    Response: In order to support better communication between the 
National Guard Bureau (NGB) and VA, a MOA was developed between VA and 
NGB to institutionalize this partnership. The national MOA between VA 
and the NGB was signed in May 2005 outlining how the two organizations 
would work together to identify and solve problems, and collaborate to 
improve communication and information flow about VA healthcare/benefits 
for Guard and Reserve members.
    On December 8, 2005, a letter and copy of that agreement was sent 
to all RO directors as well as Veterans Integrated Service Network 
(VISN) directors and VA medical center (VAMC) directors. The letter 
outlined how each RO director and VISN/VAMC director should begin to 
work with the National Guard to develop a similar local MOA with 
related state and local services and organizations. The purpose of this 
effort was to develop regional and local partnerships between VA 
leadership, National Guard Adjutants General, and State directors of 
Veterans Affairs and community agencies to enhance access and services 
for returning veterans and to integrate the delivery of services for VA 
benefits and healthcare services through the development of state 
coalitions.
    In late 2005, the NGB hired 54 National Guard transition assistance 
advisors (TAAs) (formerly called State benefits advisors)--one for each 
of the 50 states and 4 territories. With the expansion of their role, 
additional TAAs have been hired for Texas and California. The total 
number of TAAs is 57.
    The primary function of the TAA is to serve as the statewide point 
of contact and coordinator, to facilitate education and awareness for 
Guard and Reserve members and their families on VA benefits and 
services, and to assist in resolving access issues for VA healthcare, 
benefits, and TRICARE. VA hosted the first training conference in 
February 2006 on VA healthcare services, Veterans Benefit 
Administration (VBA), National Cemetery Administration (NCA) and 
TRICARE. The goal of this partnership between VA and National Guard is 
to educate all Guard members and their families on VA benefits and to 
assist with access to VA benefits and services. While the program was 
primarily set up to take care of Guard members and their families, TAAs 
provide critical support and facilitate the integration of VA and 
community services to all members of the active, Guard and Reserve 
components returning home to the State.
    VA has implemented a robust outreach program with VA staff 
participating in family day events, reunions, freedom salute and drill 
weekends with PDHRA screening events. These events provide opportune 
time for VA staff to provide one-on-one consultation to soldiers 
requesting information on VA services/benefits.
    TAAs assist National Guard and Reserve members with access to care 
and enrollment at VA healthcare facilities near their home of record. 
Additionally, they work with other Joint Forces Headquarters staff 
members and directors of State family programs to build a State 
coalition of support with VA and community organizations for Guard 
members and their families to access in their local community.
    Additionally, the TAAs were charged with working locally to develop 
and maintain State coalitions to tie together the resources of DOD, VA 
and NGB and State and local community resources in an effort to ensure 
Guard and Reserve members and their families receive the benefits and 
support when they return home. The State coalition provides a 
community-based support network of VA, State and community resources to 
assist Guard and Reserve members at the local level.
    As of December 2006, there were 25 signed local VA/NGB MOAs and 
another 21 states reported that they were in the process of developing 
a local MOA in 2007.
    An MOA is currently in the final phases of development with the 
Army Reserve that will further support effective joint work and sharing 
to serve Army Reserve component soldiers returning home. Plans are in 
process for MOAs with the USMC, Navy and Air Force similar to those 
MOAs developed with the National Guard and Army Reserve.
    In February 2007, VA again participated in the training for the 
TAAs in Phoenix, Arizona, in partnership with the National Guard family 
programs. This joint conference provided networking with the NGB State 
family programs to support the special needs of returning troops and 
families when spouses are deployed or returning home.
    With the strong support for families and existing infrastructure 
within the NGB, one of the best methods of working with the Reserve 
components has been using the TAAs as a primary point of contact for 
both the returning Guard and Reserve personnel. Many TAAs work directly 
with the Marine, Navy and Coast Guard units in their State.
                                 ______
                                 
 Response to Written Questions Submitted by Hon. John D. Rockefeller IV
    Question 1.  Overall Funding Issues. Whenever I can, I try to host 
a roundtable in West Virginia to talk to newly returned soldiers, 
including National Guard and Reservists. I learn a great deal from 
these heroes. I fully support the goals of DOD and VA in improving the 
transition, and many of the policies sound good. But when I talk to 
West Virginia veterans, I do not hear about these policies, I hear 
about problems getting care and delays in service.
    Question 1(a). What is the level of new funding committed to these 
important policies? What are top officials in DOD and VA doing to train 
staff and deliver on the good intentions and commitments?
    Response: VA has wide range of training and educational programs to 
ensure that VA clinicians and administrative staff have the tools they 
need to respond to the unique and sometimes complex healthcare needs of 
returning combat veterans. Our existing training and education 
initiatives include:
                     veterans health administration
    Tools for points of contact (POC), case managers and other front 
line staff:

     VHA published three Directives in 2006 clearly stating 
VA's expectations regarding returning OEF/OIF veterans. The three 
directives cover case management of OEF/OIF veterans, the PEB process, 
and the PDHRA program.
     VHA communicates policies, guidance and tools to assist 
front line employees via the seamless transition Intranet Web site.
     VHA hosts a monthly conference call for the VISN OEF/OIF 
POCs to discuss issues relating to OEF/OIF veterans.
     VHA maintains two e-mail groups: one for VISN POCs and one 
for VAMC POCs and case managers to facilitate dissemination of 
information on OEF/OIF veterans and discussion of issues relating to 
OEF/OIF veterans.
     VHA trained over 260 VAMC POCs and case managers to use 
the MTF tracking system (MTF2VA), which tracks servicemembers 
transitioning from MTF to VAMCs. The training also included VHA's 
expectation on the seamless transition performance measure.
     VHA developed and distributed outreach toolkits to assist 
VA staff participating in National Guard and Reserve outreach programs 
as well as PDHRA events.
     VHA in partnership with employee education service (EES) 
implemented an awareness campaign to educate VA employees on the 
seamless transition process. The awareness campaign kits, distributed 
in October 2006, contained EES brochures containing a list of 
educational products geared toward treating OEF/OIF veterans, seamless 
transition brochures, handout cards depicting the transition process 
and a video showing transition from the battlefield to VA to the 
community.

    Tools for VA healthcare providers:
     VA and DOD developed clinical practice guidelines to 
assist clinicians treating combat veterans.
     ``A Guide to Gulf War Veterans Health'' was originally on 
health care for combat veterans from the 1991 Gulf War. The product, 
written for clinicians, veterans and their families, remains very 
relevant for OEF and OIF combat veterans as many of the hazardous 
exposures are the same.
     ``Endemic Infectious Diseases of Southwest Asia'' provides 
information for health care providers about the infectious disease 
risks in Southwest Asia, particularly in Afghanistan and Iraq. The 
emphasis is on diseases not typically seen in North America.
     ``Health Effects from Chemical, Biological and 
Radiological Weapons'' was developed to improve recognition of health 
issues related to chemical, biological and radiological weapons and 
agents.
     ``Military Sexual Trauma'' was developed to improve 
recognitions and treatment of health problems related to military 
sexual trauma, including sexual assault and harassment.
     ``We are Women Veterans'' provides a personal view of the 
military experience of women.
     ``Post-Traumatic Stress Disorder: Implications for Primary 
Care'' is an introduction to post traumatic stress disorder (PTSD) 
diagnosis, treatment, referrals, support and education, as well as 
awareness and understanding of veterans who suffer from this illness.
     ``Traumatic Amputation and Prosthetics'' includes 
information about patients who experience traumatic amputation during 
military service, their rehabilitation, primary and long-term care, 
prosthetic, clinical and administrative issues.
     ``Traumatic Brain Injury'' presents an overview of TBI 
issues that primary care practitioners may encounter when providing 
care to veterans and active duty military personnel.
     All are available in print, electronic format, and on the 
Web at http://www.va.gov/VHI.

    Taken as a whole, these programs add up to a rigorous, thorough and 
systematic education and training program to ensure VA staff are 
knowledgeable about the programs and policies in place as well as the 
tools to assist them in providing care and services to OEF/OIF 
veterans. In the June 2006 the Government Accountability Office (GAO) 
report, GAO complimented VA's numerous educational activities and 
online clinical tools to ensure VA medical providers and other staff 
are aware of and recognize the healthcare needs of OEF/OIF 
servicemembers and veterans.
                    veterans benefit administration
    We are currently increasing staffing levels to reduce the pending 
claims inventory and providing the level of service expected by the 
American people. We began aggressively hiring additional staff in 
Fiscal Year 2006, increasing our on-board strength by over 580 
employees between January 2006 and January 2007.
    It is critical that our employees receive the essential guidance, 
materials, and tools to meet the ever-changing and increasingly complex 
demands of their decisionmaking responsibilities. To that end, VBA has 
deployed new training tools and centralized training programs that 
support accurate and consistent decisionmaking.
    New hires receive comprehensive training and a consistent 
foundation in claims processing principles through a national 
centralized training program called ``Challenge.'' After the initial 
centralized training, employees follow a national standardized training 
curriculum (full lesson plans, handouts, student guides, instructor 
guides, and slides for classroom instruction) available to all regional 
offices. Standardized computer-based tools have been developed for 
training decisionmakers (69 modules completed and an additional 8 in 
development). Training letters and satellite broadcasts on the proper 
approach to rating complex issues are provided to the field stations. 
In addition, a mandatory cycle of training for all Veterans Service 
Center employees has been developed consisting of an 80-hour annual 
curriculum.
    Our plan is to continue to accelerate hiring and fund additional 
training programs for new staff this fiscal year. However, because it 
requires an average of 2 or 3 years for our decisionmakers to become 
fully productive, increased staffing levels do not produce immediate 
production improvements. Performance improvements from increased 
staffing are more evident in the second and third years. We have 
therefore also increased overtime funding this year and recruited 
retired claims processors to return to work as reemployed annuitants in 
order to increase decision output.
    Since the onset of the combat operations in Iraq and Afghanistan, 
VA has provided expedited and case-managed services for all seriously 
injured OEF/OIF veterans and their families. This individualized 
service begins at the military medical facilities where the injured 
servicemembers return for treatment, and continues as these 
servicemembers are medically separated and enter the VA medical care 
and benefits systems. VA assigns special benefits counselors, social 
workers, and case managers to work with these servicemembers and their 
families throughout the transition to VA care and benefits systems, and 
to ensure expedited delivery of all benefits.
    The Secretary of Veterans Affairs recently announced a new 
initiative to provide priority processing of all OEF/OIF veterans' 
disability claims. This will allow all the brave men and women 
returning from the OEF/OIF theatres who were not seriously injured in 
combat, but who nevertheless have a disability incurred or aggravated 
during their military service, to enter the VA system and begin 
receiving disability benefits as soon as possible after separation.

    Question 1(b). Will DOD and VA be seeking additional funding to 
meet the health care needs of our returning veterans?
    Response: For Fiscal Year 2007, VA will have the funding it needs 
to support the health care needs of our returning veterans and all 
veterans seeking care.

    Question 2. Mental Health and Suicide. Last year, I cosponsored 
legislation with Senator Harkin and others to address the tragedy of 
suicides among our returning veterans. There have been too many 
tragedies, including ones in Iowa and West Virginia.

    Question 2(a). I realize that OMB prevents direct comments on 
legislation, but we all know that mental health care is an enormous 
need given the overwhelming stress of serving in Iraq and Afghanistan. 
We know there is a stigma about seeking mental health care. Some 
estimate that only 26 percent of veterans get formal mental health 
care.
    Response: VHA is implementing a comprehensive program to prevent 
veteran suicides that is analogous in many respects to the programs 
proposed in both the House and Senate. It includes initiatives to 
further enhance the capacity, access and quality of overall mental 
health programs as well as activities that directly focus on suicide 
prevention. One of the major components will be funding for suicide 
prevention coordinators in each medical center as of the third quarter 
of Fiscal Year 2007.

    Question 2(b). GAO says that $100 million of VA funding for mental 
health went unspent. This is wrong. Why aren't we doing more on mental 
health care, and particularly suicide prevention and awareness?
    Response: When GAO stated that VA funding for mental health went 
unspent, they were referring to delayed spending of approximately $86 
million of $200 million that was available to enhance mental health 
services last year. This figure represents 3.6 percent of the total 
$2.4 billion spent for mental health services last year. It represented 
a slowed rate of enhancement, not a decrease in services. The delay was 
related to education, training, and both program and staff development 
activities that were necessary to ensure that funds, when spent, would 
be used effectively and efficiently to improve care. For Fiscal Year 
2007, VHA is allocating $306 million to enhance mental health programs, 
with still more increases projected for Fiscal Year 2008.

    Question 3. Timely Access to Care for National Guard and 
Reservists. I have heard from West Virginia National Guard personnel of 
several instances in which the standards you established in your 
October 2003 policy regarding timely access to care have not been met 
for Guard soldiers returning to the civilian world from deployment in 
Iraq and Afghanistan. It appears that the major injuries are usually 
taken care of prior to discharge from active duty, but then after they 
return home, the soldiers slip through the cracks for care recommended 
by their doctors for less critical combat injuries.

    Question 3(a). What are you doing to ensure that these combat 
veterans receive all of the care that they need and that their doctors 
have recommended, and that they receive it on a timely basis? Have you 
established an effective quality control system?
    Response: All Guard/Reserve soldiers, sailors, airmen and Marines 
separating from active duty to continued Reserve status or to civilian 
status have the opportunity to attend the transition assistance program 
(TAP) briefings at each of the demobilization sites. In this program 
they first learn about VA healthcare services (and how to enroll in 
care), VA benefits and how to file for disability claims with VA. This 
is the first opportunity to learn about healthcare services, the 2 
years of eligibility for VA healthcare (also 180 days of continued 
TRICARE healthcare) and 90 days to receive dental care at VA. While 
still at the demobilization station, all servicemembers while on active 
duty complete the PDHA and they are also given the opportunity to see a 
DOD healthcare provider for care prior to leaving the demobilization 
station for home and being separated from active duty.
    Once the veteran is home, they schedule a VA primary care clinic 
appointment after enrolling in VHA care and will in most cases receive 
a VA appointment within 30 days for evaluation of their deployment-
related condition. While they attend the clinic appointment, a series 
of screening exams are performed such as for PTSD, depression, alcohol 
abuse, military sexual trauma, etc. Additional referrals are made for 
specialty care as the primary care provider requests follow-up of any 
medical condition which has been identified in the screening or 
physical examination. These times for receiving primary care 
appointments are tracked as national performance measures to ensure 
that Guard/Reserve members receive the care that they need in a timely 
manner and for all the conditions that have been caused or aggravated 
through their combat deployment.
    An additional program that offers screening for physical/mental 
health conditions occurs at the unit or use of a call center for 
screening exams for lingering mental health/physical conditions that 
are experienced at 90-180 days when they return home. This is a 
coordinated effort between VA and DOD (specifically the Guard/Army 
Reserve) to offer a screening exam and schedule appointments to VA, 
TRICARE or private physicians for further evaluation of these 
deployment-related conditions. VA staff members are present at the unit 
to accept referrals and schedule appointments to the local VA for 
follow-up evaluation for any physical or mental health condition. 
Again, Guard/Reserve members will receive appointments for primary care 
within 30 days and Vet Centers. Guard/Reserve members may choose to 
visit a civilian provider through TRICARE or use their private 
insurance from their civilian employer.

    Question 3(b). Is there an appeal or grievance process through the 
Veterans Affairs system?
    Response: For healthcare services, each VAMC has a patient advocate 
to assist with complaints for care or issues concerning eligibility. At 
each VAMC there is also an OEF/OIF coordinator who is an ombudsman for 
the Guard/Reserve or active duty servicemember requesting healthcare. 
Since many of the Guard/Reserve members are new to VA, they are 
frequently escorted to the eligibility clerk at the VAMC who will begin 
the enrollment process and facilitate appointments.

    Question 3(c). What can be done to meet the health insurance needs 
of our medically retired National Guard members and their families?
    Response: The medically retired veteran will continue to receive 
healthcare at the local VAMC and Vet Center for the condition of their 
disability as well as other conditions that may appear later. These 
members may also be eligible for DOD benefits; however, we defer to DOD 
for additional information.

    Question 4. Information Sharing. What can be done to facilitate a 
more efficient flow of communication between military medical 
facilities, to include Community Based Health Care Organization (CBHCO) 
and Military Treatment Facilities (MTF), and the individual state 
Adjutant General when an injured soldier transitions from one duty 
status to another?
    (From the National Guard's point of view, there should be a point 
of contact clearly identified or established at every military medical 
facility, including CBHCOs and MTFs, who would be responsible for 
notifying the soldier's Adjutant General when the soldier is admitted, 
discharged or transported to another facility. The Adjutant General 
would then assure the delivery of transitional benefits access and 
counseling to include Veterans Affairs healthcare options, TRICARE 
programs that may be available, VA benefits counseling such as home 
loan guarantee, education benefits, and or vocational rehabilitation 
services.)
    Response: Each of the 10 MTFs where the large number of severely 
injured servicemembers receive their initial care, have VA/DOD liaisons 
and VBA counselors embedded with DOD staff to facilitate the transition 
from DOD to VA to the community. Case managers in Medical Holdover and 
the eight community based healthcare organizations (CBHCO) are 
activated Guard Nurses who notify the Adjutant General or the J-1 staff 
in each State about the health and transition status of the active duty 
servicemembers in these programs. The TAAs in each State work for the 
Adjutant General and are trained by VA experts to assist the State 
director of Veterans Affairs in notification of returning 
servicemembers to the State. They coordinate with the J-1 staff in the 
State for updates of those returning servicemembers/veterans back to 
the State. They also help to facilitate the briefings to returning 
soldiers to ensure that they receive Federal and State veterans 
benefits when they transition from active duty to veteran status. The 
TAAs work collaboratively with the State family program directors to 
provide VA information to them for their retiring spouse.
    The Adjutant General, TAA and J-1 staffs assure access and 
counseling on transitional benefits to include VA healthcare options, 
TRICARE options, VA benefits such as home loan guarantee, education 
benefits, and vocational rehabilitation services. State directors of 
Veterans Affairs, county service officers, veterans' service officers 
as well as VA staff from the hospital and regional office participate 
in the PDHRA events to provide outreach information to new veterans.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. Barack Obama
    Question 1.  Electronic Health Records. As part of last October's 
Defense Authorization Bill, Congress required a report on the 
feasibility of providing each servicemember with a secure electronic 
copy of their health and service records. I was hoping you could 
discuss the importance of the DD214 form to veterans applying for 
benefits and healthcare and the potential advantages of giving veterans 
more specific data about their service and medical histories through an 
individual electronic health record.
    Response: VA and DOD have made significant progress in sharing 
electronic health information and lead the Nation in sharing electronic 
health data between two large medical enterprises. Veterans' benefits 
claims adjudicators have electronic access to the DD214 by using the VA 
personnel information exchange system to connect to the Defense 
personnel records retrieval system portal to the official military 
personnel files maintained by the services. The DD214 is a part of that 
official military personnel file and is an essential document for all 
veterans when they apply for VA benefits
    Veterans also have increasing access to their own medical 
information and other important health data through My HealtheVet 
(MHV). VA has currently deployed MHV as the eHealth portal and personal 
health record (PHR) for veterans and VA employees. MHV continues to 
release new iterations, and now includes a robust self-entered PHR, 
Internet prescription refill capability, and targeted clinical health 
information for conditions and healthy living. Participants can enter 
information about their health, conditions, medications, and care 
providers in one secure electronic eVAult; track health readings (e.g., 
blood pressure and blood sugar); keep health journals (e.g., food and 
activity journals); and print out summaries for their various health 
care providers. In December 2006, VA launched the second generation of 
the PHR. Veterans who receive care in the VA system may now choose to 
upgrade their account by undergoing a face-to-face authentication at an 
authorized VA care facility. They then can elect to receive more 
identifiable health information from VA's VistA electronic health 
records, such as their appointments, medication names and laboratory 
results. The rollout of this VistA electronic health records 
information to MHV PHR is expected to take place over the coming year, 
and will include training for clinicians and patients, as specified by 
the VA clinical and patient education community. The use of information 
technology to improve the Veteran experience is a high priority. VA is 
actively working to help lead the Nation into a future of patient-
centered health information.

    Question 2. Aggregate Health Data. I am concerned that the military 
is not giving VA enough concrete data to help them conduct long-term 
planning. Let's take mental health as an example. The Army's Mental 
Health Advisory Team found that soldiers who deployed to Iraq for a 
second time were more likely to suffer mental health problems. Absent 
that data, what kind of data is VA using to anticipate the demand for 
mental health care? Did VA anticipate that 36 percent of Iraq/
Afghanistan veterans entering the VA would require mental health 
treatment?
    Response: In additional to available data to project current demand 
for mental health services from servicemembers from OEF/OIF, VA looks 
at historical medical treatment trends from past periods of war. VA 
also considers capacity needs to meet that demand by conducting reviews 
of literature, past VA and DOD epidemiological studies, and utilization 
records. Based on our reviews, we anticipated that a proportion of OEF/
OIF veterans would require mental health services.
    VA anticipated that 36 percent of OEF/OIF veterans entering VA 
would require mental health treatment based on review of the research 
conducted since the time of the Vietnam War, which found that 
increasing exposure to war zone stressors can result in an increase in 
vulnerability to PTSD and associated mental and emotional problems. 
Data from various studies of veterans of previous wars suggested that 
overall, the rate of mental problems can be in the range of 15-26 
percent, or higher in certain populations exposed to extreme stress 
such as prisoners of war. That the number of veterans coming to VHA has 
a rate of mental problems in the 30 percent range has been evident 
since we began tracking the utilization rates for VHA services for 
returning OEF/OIF veterans in Fiscal Year 2002.

    Question 3. Falling through the Cracks. In an average year, 10,000 
to 20,000 servicemembers are separated from the military through the 
Medical Evaluation Board and Physical Evaluation Board Process. These 
are soldiers who, because of a physical or mental health problem, are 
unfit to be deployed.
    Question 3(a). How many of these troops had benefits claims filed 
before they discharged?
    Response: Servicemembers undergoing medical evaluation board (MEB) 
or PEB proceedings with a discharge date are currently included in the 
BDD program. There were approximately 36,000 claims filed through the 
BDD program in Fiscal Year 2006. VBA does not separately track MEB/PEB 
cases; rather, all BDD cases are tracked and handled expeditiously.

    Question 3(b). How many had their first VA medical appointment 
scheduled before they discharged?
    Response: Medical appointments are made according to the patient's 
clinical need. For the seriously injured patients requiring inpatient 
rehabilitation and transfer from a DOD MTF to a VAMC, medical 
appointments are made prior to hospital discharge in all cases. 
Patients who are discharged from the DOD treatment facility to 
outpatient status elect where they will get their outpatient medical 
care. That care may or may not be provided by a VA treatment facility. 
If the patient elects to receive his or her care in the VA system, the 
VA personnel in the DOD treatment facility coordinate the appointment 
prior to discharge.

    Question 3(c). What kind of comprehensive case management is being 
offered to these troops?
    Response: Each VAMC has designated an OEF/OIF clinical case manager 
to provide ongoing case management services to returning OEF/OIF 
servicemembers, veterans and their families. Although many OEF/OIF 
patients may not require intensive case management, VA requires the 
case manager to conduct an initial assessment to identify and assist 
with immediate needs. Patients with severe injuries or having complex 
needs will receive ongoing case management as their medical and 
psychosocial needs dictate. The case manager is accessible to the 
patient and family should additional needs arise in the future. In 
addition, VA requires that polytrauma patients receiving treatment at 
one of VA's four polytrauma rehabilitation centers receive social work 
case management services at a ratio of one social work case manager for 
no more than six OEF/OIF polytrauma inpatients.
    VBA counselors and VHA social worker liaisons have been established 
at MTFs. ROs have established liaison with local MTFs to ensure contact 
with seriously injured OEF/OIF veterans. VBA counselors at key MTFs or 
VA medical facilities meet with every injured OEF/OIF servicemembers 
when medically appropriate. The servicemembers are made aware of all 
potential VA benefits and services as well as other benefits and 
services available through other sources. They are assisted in 
completing their claims and gathering supporting evidence. While 
servicemembers are hospitalized, they are routinely informed about the 
status of all of their pending claims. Servicemembers are given a 
business card that contains the VBA counselors name and contact 
information such as a telephone number.

    Question 3(d). Concerning the 631,000 total Iraq/Afghanistan 
veterans, wounded or otherwise, what kind of one-on-one transition 
assistance did these veterans receive?
    Response: VA provides outreach to all returning servicemembers to 
inform them of the benefits and services for which they may be 
eligible. VA provides pre- and post-mobilization briefings as well as 
3-day TAP workshops and disabled transition assistance program (DTAP) 
workshops which advise injured/ill servicemembers about benefits 
available through VBA's Vocational Rehabilitation and Employment 
Program. To assist recently separated veterans, the Veterans assistance 
at discharge system (VADS) process generates a ``Welcome Home Package'' 
that includes a letter from the Secretary, VA Pamphlet 21-00-1, A 
Summary of VA Benefits, and VA Form 21-0501, Veterans Benefits 
Timetable. Servicemembers receive one-on-one transition assistance 
through the BDD program which allows servicemembers to begin the VA 
disability examination process up to 180 days prior to discharge.
    Veterans service center case managers are assigned for each 
compensation claim received from a seriously disabled OEF/OIF 
servicemember. The case manager becomes the primary VBA point of 
contact for claims processing; however, the VBA counselors at the MTF 
may continue to be involved if the servicemember is still a patient at 
the MTF.
    VA continues to explore additional ways to meet the needs of both 
the active duty and Reserve and Guard members supporting OEF/OIF. The 
Secretary of Veterans Affairs just announced that VA is beginning a new 
initiative to provide priority processing of all disability 
compensation claims from OEF/OIF veterans. A second component of this 
initiative is focused on identifying additional enhancements that can 
be made to our outreach program for Reserve and Guard members. The 
Secretary is also creating a special Advisory Committee on OEF/OIF 
veterans and families, which will advise on the full spectrum of issues 
affecting these veterans and their families.

    Question 4. Aggregate Health Data. The Pentagon provides limited 
data to the VA about servicemembers when they are separating, but does 
not provide comprehensive systematic data on the numbers of wounded 
that could help VA in long-term planning. A recent Harvard report put 
the number of American servicemembers wounded in Iraq and Afghanistan 
at more than 50,500. Some of these soldiers are sent to military 
hospitals in the U.S., but many are healed and returned to service. VA 
polytrauma facilities often care for injured Active Duty troops. What 
kind of lead time does the Pentagon give the VA before transferring 
these patients to VA care? What does that do to your budget planning?
    Response: The time between notification of the Polytrauma 
Rehabilitation Centers' (PRC) intent to transfer a seriously injured 
servicemember or veteran to a VA health care facility and actual 
patient transfer is variable. That time can be hours, days or weeks 
before transfer. The process involves exchange of clinical information 
regarding patients to be transferred from the MTF. The VA Polytrauma 
system of care uses this information to monitor capacity and to plan 
clinical care.
    As to budget planning, the budget estimates are updated each year 
with the most current information available. This helps to ensure that 
the budget estimates are consistent with changes in the numbers of 
patients treated.

    Question 5. Total Costs of Caring for OEF/OIF Veterans. A recent 
report by the Kennedy School of Government at Harvard put the lifetime 
costs of caring for Iraq/Afghanistan veterans at $350 to $700 billion. 
Do you agree with this estimate, and if not, what estimate can you 
offer in its place?
    Response: The Administration reviews and funds the needs of 
veterans 1 year at a time. In Fiscal Year 2008, VA estimates that it 
will treat over 263,000 OIF/OEF veterans at a cost of approximately 
$752 million. This estimate is based on the actual enrollment rates, 
age, gender, morbidity, and reliance on VA health care services of the 
enrolled OIF/OEF population. OIF/OEF veterans have significantly 
different VA health care utilization patterns than non-OIF/OEF 
enrollees, and this is reflected in the estimates above. For example, 
when modeling expected demand for PTSD residential rehab services for 
the OIF/OEF cohort, the model reflects the fact that they are expected 
to need three times the number of these services than non-OIF/OEF 
enrollees. The model also reflects their increased need for other 
health care services, including physical medicine, prosthetics, and 
outpatient psychiatric and substance abuse treatment. On the other 
hand, experience indicates that OIF/OEF enrollees seek about half as 
much inpatient acute medicine and surgery care from the VA as non-OIF/
OEF enrollees.
    At this point in time, the full impact of the conflict remains 
uncertain. Many unknowns will influence the number and types of 
services that VA will need to provide OIF/OEF veterans, including the 
duration of the conflict, when OIF/OEF veterans are demobilized, and 
the impact of our enhanced outreach efforts. VA has estimated the 
health care needs of OIF/OEF veterans based on what we currently know 
about the impact of the conflict. To ensure that we are able to care 
for all returning OIF/OEF veterans, we have made additional investments 
in our medical care budget.

    Chairman Akaka. Thank you. Thank you very much.
    May I now ask, Secretary Chu, for your statement.

 STATEMENT OF HON. DAVID S.C. CHU, UNDER SECRETARY OF DEFENSE 
       FOR PERSONNEL AND READINESS, DEPARTMENT OF DEFENSE

    Dr. Chu. Good morning, Mr. Chairman, Members of the 
Committee. I have a statement for the record which I hope will 
be included in the proceedings of this hearing. It is a 
distinct privilege to appear with Gordon Mansfield----
    Chairman Akaka. It will be included in its entirety.
    Dr. Chu. Thank you, sir. It is a distinct privilege to 
appear here this morning with Gordon Mansfield, the Department 
of Defense Council and Secretary Mansfield, as our partner in 
addressing the issues that Members of the Committee have 
outlined this morning. I want to thank him and his predecessor, 
Leo McKay, for the partnership they have created over these 
last 6 years. It is a different relationship than it was 6 
years ago, and I think the reason for that difference is 
commitment--commitment by the Administration, commitment by the 
two Cabinet Secretaries, commitment by the individuals up and 
down the line in the two agencies that are responsible for our 
military personnel and the veterans of the United States.
    The mechanism we use to move forward improvements to 
service in the two Cabinet Departments is, as Secretary 
Mansfield alluded, the so-called Joint Executive Council. This 
was formed during this Administration, sanctioned by the 
earlier President's Task Force to Improve Health Care for our 
Nation's Veterans, and enshrined in statute by the Congress. It 
oversees the work of the two separate councils--one on health, 
one of benefits--both devoted to strengthening the services and 
improving the delivery of services to our Nation's veterans. 
The guidance document that we use is an annual Joint Strategic 
Plan that outlines goals in the six key areas touching on the 
very issues that Members of the Committee have addressed this 
morning.
    I believe that if you look at the record over the last half 
a dozen years, you will see progress in every area that your 
letter of invitation outlined, Mr. Chairman. I would like to 
call attention to just two issues of particular concern that 
are highlighted this morning, those being health and the 
transition to civil life.
    In the health arena, the Department now assesses the health 
status of each departing, deploying servicemember before he or 
she goes overseas. When the servicemember returns, there is a 
parallel assessment. That is the source of data on issues like 
mental symptoms, et cetera. And realizing especially that post-
traumatic stress disorder will not necessarily evince itself at 
the point of return, we reach out to all returning 
servicemembers, including those who have left active duty, 3 to 
6 months after that service. So there is now a record of their 
status at these three key points in time.
    We recognize that the two Departments have a special 
responsibility to those who have severe injuries. Each military 
service has its own program for caring for these individuals 
and assuring that their needs are met, but to be doubly sure 
that there is no issue that falls through the cracks, we 
constituted several years ago a Military Severely Injured 
Center. Its responsibility is to pick up on any issue that an 
individual might have. Those range from how the Transportation 
Security Agency treats veterans who may have prosthetic 
devices--for example, implants of various kinds--when they 
transition airport security, through the issue of what will 
their future look like. And, indeed, the model to which we are 
moving is one in which we proffer opportunities to them rather 
than waiting for them to seek out the opportunities that may be 
there. And certainly, the Department of Defense and I think the 
Veterans Affairs Department has a similar view. We view these 
as potentially attractive individuals who might well qualify 
for civil employment in our agencies, bring to those agencies 
the knowledge, the ethos, really, of military service that is 
so important to our future success.
    Transitioning to civil life is a challenge for all military 
personnel in every area. That is why the three Cabinet 
Departments have for some time now constituted the Transition 
Assistance Program. This is a multi-day program, a portion of 
which is mandatory for all separating personnel, that outlines 
the benefits to which they are entitled, outlines how they 
might approach those benefits. The Department of Labor in 
particular offers them assistance in locating positions, 
understanding what job banks are out there, and how to approach 
them, how to use the Department of Labor's decentralized job 
referral system, and how to build their resume.
    Secretary Mansfield has highlighted what I think is an 
example of the continued success of the two agencies, and that 
is the commitment to a common electronic inpatient record. We 
have now in DOD a worldwide record for outpatient care, but we 
need to create a parallel record for inpatient care. We intend 
to do that in partnership with the VA so we have a single 
record.
    Do we need to do more? Of course. Will we do more? Yes, we 
will. And, in fact, tomorrow is the next quarterly meeting of 
the very Joint Executive Council that Secretary Mansfield 
celebrated in his comments.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Chu follows:]
 Prepared Statement of Hon. David S.C. Chu, Under Secretary of Defense 
           for Personnel and Readiness, Department of Defense
    Chairman and distinguished Members of the Committee, thank you for 
the opportunity to discuss a key element in the President's Management 
Agenda--Department of Defense (DOD) and Department of Veterans Affairs 
(VA) collaboration. DOD sets a high priority on expanding existing 
efforts and identifying new opportunities for collaborative and 
cooperative activities with the VA. I am pleased to be here today to 
provide an overview and status update of many of these innovative 
programs and initiatives.
    While the two Departments have been working together in earnest for 
over two decades, the many professionals within both Departments are 
bringing DOD and VA closer together at a pace greater than at anytime 
before, under the guidance of the VA/DOD Joint Executive Council (JEC). 
The JEC provides guidance and establishes policy for the full spectrum 
of collaborative activities and initiatives between the two 
Departments. The JEC oversees and guides the activities of the VA/DOD 
Benefits Executive and Health Executive Councils (BEC and HEC, 
respectively), as well as their many working groups. The HEC is 
responsible for implementing a coordinated health care resource sharing 
program. The BEC is responsible for examining ways to expand and 
improve benefit information sharing, refining the process for records 
retrieval, and identifying procedures to improve the benefits claims 
process.
    Program managers and directors from both departments have been 
working closely with one another to improve access, quality and 
efficiency. DOD believes that none of our efforts are more important 
than creating an uninterrupted continuum of care for severely injured 
and ill servicemembers and their families, whatever their individual 
needs may be, as they transition from military service to veteran 
status.
    Tomorrow, VA Deputy Secretary Mansfield and I are scheduled to sign 
our Annual Report on Resource Sharing. The report will present in 
considerable detail what I believe are our accomplishments of the past 
fiscal year, and will offer a look into the future for our 
collaborative efforts as we endeavor to make transition between the two 
departments as seamless as possible.
    An important appendix to the report contains the third update to 
the VA/DOD Joint Strategic Plan for Fiscal Years (FY) 2001-2009. This 
plan guides our joint activities and serves as the primary instrument 
by which we measure progress and success throughout each year. As a 
testament to the firm foundation that has been established, the guiding 
principles have remained unchanged since their inaugural release in 
2004. However, the current plan reveals lessons learned in the areas of 
identifying opportunities for improvement, developing goals and 
strategies to achieve these improvements, and developing performance 
measures.
    Accordingly, my statement today will address the many activities 
under way that reflect the shared commitment to delivering care and 
benefits across our departments.
                       resource sharing overview
    Health care resource sharing is a broad term used to describe a 
wide spectrum of collaboration between DOD and VA. Within this spectrum 
lie many areas of sharing, including general and specialized patient 
care, education and training, research and development, and health care 
administrative support. The departments provide these services to one 
another under mostly local agreements that involve reimbursement or 
exchange of services. At the end of Fiscal Year 2006, DOD military 
treatment facilities (MTFs) and Reserve units were involved in sharing 
agreements with 157 VA Medical Centers.
    In addition to these local sharing agreements, which are the 
cornerstone of our collaborative relationship, there are a variety of 
systemic initiatives. Section 721 of the Fiscal Year 2003 National 
Defense Authorization Act (NDAA) required VA and DOD to establish an 
account in the Treasury, referred to as the Joint Incentive Fund (JIF), 
and fund the account on an annual basis. The JIF is intended to 
eliminate budgetary constraints that deter sharing initiatives by 
providing funding to cover the startup costs associated with innovative 
and unique sharing agreements. JIF projects are selected using criteria 
that include improvements in access, return on investment, and overall 
contributions to the goals and objectives of the Joint Strategic Plan. 
Fiscal Year 2006 projects embraced a broad spectrum of health care 
programs: mental health counseling, Web-based training for pharmacy 
technicians, cardio-thoracic surgery, neurosurgery, and increased 
physical therapy services for both DOD and VA beneficiaries. At the end 
of Fiscal Year 2006, 47 JIF projects accounting for $88.8 million of 
the $90 million in the fund had been approved by the HEC from a total 
of over 200 proposals.
    Section 722 of the Fiscal Year 2003 NDAA mandated the DOD and VA to 
execute no less than three health care coordination demonstration 
projects over a 5-year period. There are seven sites currently testing 
initiatives such as the Bi-Directional Health Information Exchange, on 
which I will elaborate later, as well as a Laboratory Data Sharing 
Initiative and Joint Market Workload Data Analysis.
    The DOD and VA also collaborate extensively in the area of 
education and training. There are 159 VA/DOD agreements involving 
education and training, including training for physicians and nurses. 
In Fiscal Year 2006, the HEC continued to monitor a pilot program for 
military physician residents placed at academically affiliated VA 
medical centers. The military residents rotate through VA facilities 
and provide care to VA patients under the supervision of university 
faculty.
                         collaboration results
    While resource sharing is a fundamental part of our relationship 
with the VA, I am proud that this partnership has expanded further and 
now entails a significant number of programs within both the DOD 
personnel and health affairs communities. A particular focus is 
facilitating a coordinated transition, enabling servicemembers, 
veterans, and their families to navigate a complex benefits systems 
with relative ease--a seamless transition. I will describe several of 
our ongoing efforts.
     One program under the purview of the BEC facilitated 130 
Memoranda of Understanding between local DOD and VA facilities for a 
cooperative separation physical examination process. This program, 
called Benefits Delivery at Discharge (BDD), brings claims specialists 
from the Veterans Benefits Administration (VBA) to assist separating 
servicemembers in filing disability claims as soon as 6 months before 
they leave uniform. According to VA, BDD has reduced the average time 
for an adjudication decision to approximately 60 days.
     The Army Liaison/VA Polytrauma Rehabilitation Center 
Collaboration program, a ``Boots on the Ground'' program, stood up in 
March 2005. The intent of this collaborative effort is to ensure that 
severely injured servicemembers who are transferred directly from an 
MTF to one of the four VA Polytrauma Centers in Richmond, Tampa, 
Minneapolis, and Palo Alto, are met by a familiar face in a uniform. 
DOD has a long-standing relationship with the VA, in which VA provides 
rehabilitative services for patients with traumatic brain injuries, 
amputations, and other serious injuries as soon after the incident as 
clinically possible. A staff officer or non-commissioned officer 
assigned to the Army Office of the Surgeon General is detailed to each 
of the four locations. The role of the Army liaison is primarily to 
provide support to the family through assistance and coordination with 
a broad array of issues, such as travel, housing, and military pay. The 
liaisons have also played a critical role in the rehabilitation process 
by promoting resiliency in servicemembers. The presence of a uniformed 
liaison reassures these servicemembers and their families that we 
appreciate their service and are committed to ensuring their needs are 
met by our sister agency.
     The Joint Seamless Transition Program, established by VA, 
in coordination with the Military Services, facilitates a more timely 
receipt of benefits for severely injured servicemembers while they are 
still on active duty. There are 12 VA social workers and counselors 
assigned at 10 MTFs, including Walter Reed Army Medical Center and the 
National Naval Medical Center in Bethesda. They ensure the seamless 
transition of health care includes a comprehensive plan for treatment. 
VBA counselors visit all severely injured patients and inform them of 
the full range of VA services, including readjustment programs, and 
educational and housing benefits. As of December 15, 2006, VA social 
worker liaisons had processed 6,714 new patient transfers to Veterans 
Health Administration (VHA) at the participating military hospitals.
    VA social workers work on-site at the MTFs to respond to referrals 
to coordinate inpatient care and outpatient appointments at a VA 
medical center near the patient's intended residence. They coordinate 
transfer of care and maintain follow-up with patients to verify success 
of the discharge plan, and to ensure continuity of therapy and 
medications. Case managers also refer patients to Veterans benefits 
counselors and vocational rehabilitation counselors.
     The Department is committed to providing the assistance 
and support required to meet the challenges that confront our severely 
injured and wounded servicemembers and their families during the 
difficult time of transition. Each military Service has programs to 
serve their severely wounded from the war: the Army Wounded Warrior 
Program (AW2), the Navy SAFE HARBOR program, the Air Force Helping 
Airmen Recover Together (Palace HART) program, and Marine4Life Injured 
Support Program. DOD's Military OneSource Center is part of this effort 
to augment the support provided by the Services. It reaches beyond the 
DOD to other agencies, the nonprofit world and corporate America. What 
makes the Center unique is that it serves as a fusion point of four 
Federal agencies--DOD, the VA, the Department of Homeland Security's 
Transportation Security Administration, and the Department of Labor.
    The BEC also monitors the implementation of Traumatic Injury 
Protection under Servicemembers' Group Life Insurance (TSGLI) program 
authorized by Public Law 109-80. The first payments under this 
authority were released on December 22, 2005, and as of the end of 
Fiscal Year 2006, 2,607 claimants were paid a total of $170 million 
with the average payment at just over $65,000.
                        high quality health care
    Having the right programs in place is not enough. There must be an 
unyielding commitment to quality when it comes to providing world-class 
health care to our Nation's servicemembers and veterans. Thus, in 
addition to the four VA Polytrauma Centers and VA social workers in 
place at select MTF's, VA and DOD have also begun or expanded 
collaborative programs in the areas of deployment health, evidenced-
based clinical practice guidelines, and patient safety.
                           deployment health
    DOD has been performing health assessments on servicemembers prior 
to and just after deployment for several years now. These assessments 
serve as a screen to identify any potential health concerns that might 
warrant further medical evaluation. This includes screening the mental 
well-being of all Soldiers, Sailors, Airmen and Marines in both the 
Active and Reserve Components.
    Every year, members are screened for mental health problems when 
they complete a preventative health assessment. Now, they are again 
screened before they deploy. In addition, before returning home from 
deployment, members complete a post deployment health assessment, which 
contains questions aimed at identifying physical or mental health 
concerns; environmental exposure concerns; psychosocial concerns, such 
as acute post traumatic stress disorder, depression, anger, or inter-
personal conflict; and potentially unexplained symptoms.
    The Services are now implementing an additional health reassessment 
that is conducted 3-6 months after returning home--the Post Deployment 
Health Re-Assessment. Our experience has taught us that problems are 
not always apparent at the time servicemembers are immediately 
returning home, but they may surface a few weeks or months later. We 
want to assist in early identification of these concerns and facilitate 
ready access to care at the level most appropriate to the individual 
servicemember.
                          clinical guidelines
    DOD and VA have worked hard to develop joint evidenced-based 
clinical practice guidelines. The medical literature supports the 
premise that guidelines reduce variations in care, optimize patient 
outcomes, and improve the overall health of beneficiaries. There is a 
working group that works specifically on developing, updating, and 
promulgating these guidelines to clinicians in both health care 
systems.
    Because of challenges faced by our forces, some servicemembers may 
develop chronic mental health symptoms. Mental health experts from the 
DOD and VA developed joint clinical practice guidelines for acute and 
post traumatic stress disorder, major depressive disorder, substance 
use disorders, medically unexplained symptoms, pain, and general post 
deployment health concerns. DOD uses all available resources, including 
local military or TRICARE providers (a benefit extended for up to 180 
days post deactivation for Reservists), to provide treatment for 
affected servicemembers. VA is a partner in this process by providing 
health care and counseling services to Operation Enduring Freedom (OEF) 
and Operation Iraqi Freedom (OIF) veterans who are no longer on active 
duty.
                             patient safety
    In addition to deployment health, the HEC is committed to ensuring 
that care is delivered with the absolute least risk to the patient. DOD 
and VA have highly respected patient safety programs and work with 
other government agencies, such as the Centers for Disease Control and 
Prevention and the Food and Drug Administration, to prevent harm to 
patients while they are receiving care. As a prime example of working 
together to minimize risk of adverse events and to support the 
commitment to provide the best health care treatment outcomes, in 
Fiscal Year 2006 DOD implemented a system for developing patient safety 
alerts that was modeled on the VA's system.
                        efficiency of operations
    The JEC is committed to efficiency. Through the VA/DOD Acquisitions 
and Pharmacy Working Groups, the two departments have achieved 
substantial savings to the taxpayer, obtaining economies of scale 
through joint purchasing of capital equipment and pharmaceuticals.
    These working groups recently reported there are currently 46 
shared contracts for medical and surgical equipment contracts: the 
Defense Supply Center Philadelphia reported sales in Fiscal Year 2006 
from these contracts in excess of $170 million and VA reported another 
$201.5 million. The Pharmacy Working Group reported 77 Joint National 
Contracts that resulted in a combined cost avoidance of $423 million 
for pharmaceutical purchases in the first three quarters of Fiscal Year 
2006.
                          information sharing
    The programs and benefits earned by servicemembers could not be 
delivered without complete cooperation between the DOD and the VA in 
the area of information sharing. Indeed, information sharing is 
critical to an effective and transparent transition process, and that 
is why so much attention is paid to information management and 
information technology in the Joint Strategic Plan.
    Important to health care related information sharing is the 
requirement to comply with the Health Insurance Portability and 
Accountability Act (HIPAA). DOD and VA signed a Memorandum of Agreement 
governing the sharing of Protected Health Information (PHI) and other 
individually identifiable information in June 2005.
    The Federal Health Information Exchange (FHIE) supports the monthly 
electronic transfer of health information from DOD to VA at the time of 
the servicemember's separation. The data contained in this transfer 
include: pharmacy and allergy data; laboratory and radiology results; 
consult reports; discharge summaries; admission, disposition and 
transfer information; and patient demographic information. Health care 
providers within VHA, and benefits counselors within VBA, access this 
information via the Computerized Patient Record System and Compensation 
and Pension Records Interchange, respectively. As of the end of Fiscal 
Year 2006, DOD had transmitted health data on over 3.6 million 
patients. DOD uses FHIE to transmit data to the VA regarding VA 
patients receiving care within an MTF, and has sent over 1.8 million 
individual transmissions.
    FHIE is also being used as a platform from which DOD transmits pre- 
and post-deployment assessment information for separated servicemembers 
and demobilized Reservists and Guardsmen. Over 1.5 million assessments 
on more than 623,000 individuals have been electronically transmitted 
to VA.
    Building from the FHIE, which is a one-way flow of information, DOD 
and VA have developed and begun deployment of the Bidirectional Health 
Information Exchange (BHIE). This exchange enables near real time 
sharing of allergy, outpatient prescription, inpatient and outpatient 
laboratory and radiology results, and demographic data between DOD and 
VA for patients treated by both departments. BHIE is operational at all 
VA medical centers and at 14 DOD medical centers, 19 hospitals, and 
over 170 outlying clinics.
    With an eye toward the future, the VA/DOD Health Information 
Technology Sharing Working Group began in Fiscal Year 2006 to establish 
an interface between BHIE and the DOD Clinical Health Data Repository 
in order to accelerate progress in sharing appropriate health 
information. This interface will ensure that all VA sites and all DOD 
sites worldwide will have the ability to view data from the other 
department for shared patients. We are also focusing on increasing the 
amount of inpatient data exchanged. Most recently, BHIE began to 
exchange inpatient and emergency department discharge summaries. Other 
inpatient documentation, such as operative reports and inpatient 
consultations, are planned for the future.
    DOD is aware of the concerns regarding the time it has taken to 
establish the desired level of interoperability. With the full 
deployment of DOD's electronic health record (EHR)--AHLTA--across the 
Military Health System accomplished, we are poised to continue building 
on our significant achievements in sharing critical health information 
across department lines. The ultimate desired end-state will be a 
completely electronic health care record that is accessible and useable 
to the provider regardless of which health care system they are 
operating within.
    In pursuit of that goal, DOD and VA are developing an assessment of 
the clinical workflow and health information for the care of 
inpatients. Management of inpatient care is a future capability planned 
for AHLTA. VistA, the VA EHR, supports ambulatory care plus a 
segmentable but integrated inpatient care capability. VA is planning to 
modernize VistA, including its inpatient module. We believe that this 
is an opportunity to explore a ``born seamless'' approach for a joint 
inpatient EHR.
    I want to discuss two additional information sharing programs that 
provide VA with essential data in order to expedite the benefits 
delivery process. First, DOD is providing contact information for 
servicemembers when they separate. DOD began routinely providing VA 
rosters on recently separated OEF and OIF veterans--Active Duty and 
Reserve Components--in September 2003. VA uses these lists to send 
letters to veterans containing information on VA benefits related to 
service in a combat theater. Over 580,000 letters have been mailed.
    Second, DOD is transmitting to VA's Office of Seamless Transition a 
monthly list of key demographic and contact information about 
servicemembers for whom a Medical Evaluation Board has referred them to 
a Physical Evaluation Board. This list enables VA case managers to make 
contact with servicemembers at the earliest time possible, while they 
are still in uniform. By the end of Fiscal Year 2006, DOD had provided 
VA with contact information for 13,622 individuals.
    To support streamlined benefits processing and reduce operating 
costs, VA and DOD continue to develop and implement military personnel 
data sharing initiatives under the auspices of the BEC. Movement toward 
a single bidirectional data feed between VA and DOD is achieved by 
incorporating necessary data sets into a data sharing schema and then 
eliminating legacy feeds. Specific data sets incorporated into the VA/
DOD data sharing schema in Fiscal Year 2006 include Reserve and Guard 
activation and mobilization data, deployment data and combat pay 
indicators on all servicemembers and veterans, education eligibility 
data enhancements which support the Montgomery GI Bill and Montgomery 
GI Bill Selected Reserve programs, and medical eligibility for combat 
injuries. Additionally, DOD also made the Defense Personnel Records 
Information Retrieval System available to VA online to enhance VA 
employees' access to the Official Military Personnel File. In Fiscal 
Year 2006, the number of separate data exchanges flowing from DOD to VA 
were reduced from 31 to 20. From VA to DOD, the number of separate data 
exchanges dropped from 11 to 8.
                                outreach
    Arguably the most important link in the value chain is the level of 
awareness and understanding among our beneficiaries and employees 
regarding the myriad benefits, their disparate eligibility criteria, 
and the processes for obtaining those benefits. Education and outreach 
must occur at multiple intervals throughout a servicemember's career, 
beginning at accession into the military. The BEC has overseen the 
establishment and expansion of such programs. In November 2004, VA 
began distributing a pamphlet entitled A Summary of VA Benefits to all 
Service inductees at the Military Entrance Processing Stations. This 
year, distribution of this pamphlet was expanded to the Military 
Service Academies for graduates about to receive their commissions.
    There has also been an increased emphasis on training our employees 
and familiarizing them with their VA counterparts. While we often talk 
about coordinated transition in terms of programs and initiatives, a 
smooth transition requires personnel to understand the other 
department. It also means developing working relationships at the point 
of care or service. DOD has dedicated a series of presentations to this 
important topic within the annual Military Health System Conference, 
which is attended by leadership and professional staff from DOD sites 
across the globe. We also presented VA/DOD Collaboration and 
Coordinated Transition as a plenary session at the annual TRICARE 
Beneficiary Counselors and Debt Collection Assistants Conference, 
attended by approximately 500 front-line staff who daily assist 
servicemembers, retirees and veterans in understanding their benefits.
                   dod transition assistance program
    Returning to private life after serving in the military can be a 
very complex undertaking. The DOD, VA, and the Department of Labor 
(DOL) are working together to provide servicemembers with the tools and 
information they need to fashion individual solutions to the challenges 
they face.
    The Montgomery GI Bill (MGIB) is vital to recruiting efforts--money 
for college ranks among the major reasons young men and women enlist. 
However, education is also an important transition tool, attractive to 
both servicemembers and their families. GI Bill enrollments increased 
from only 50 percent in its first year (in 1985) to nearly 97 percent 
starting in the early 1990s and continuing at that level to this day. A 
total of 2.8 million men and women, from an eligible pool of 3.8 
million, have taken advantage of the MGIB. Eligibility requires the 
Active, Guard, or Reserve member to serve at least two consecutive 
years on active duty. While a servicemember who has met the requirement 
may use the GI Bill while still serving on active duty, it is primarily 
a veteran's benefit, thus, the program is administered by the 
Department of Veterans Affairs.
    The Transitional Assistance Management Program (TAMP) offers 
transitional TRICARE coverage to certain separating active duty members 
and their eligible family members. Under the Fiscal Year 2005 NDAA, 
TRICARE eligibility under the TAMP was permanently extended from 60 or 
120 days to 180 days. After the TAMP eligibility expires, members and 
eligible family members may choose to enroll in the Continued Health 
Care Benefit Program (CHCBP). CHCBP provides a conversion health plan 
similar to TRICARE Standard for a specific time (18 months) to all 
former servicemembers and their families who pay quarterly premiums.
    DOD has improved access to the Verification of Military Experience 
and Training (VMET) document (DD Form 2586) by making it available to 
eligible members through a VMET Internet site. This document provides 
descriptive summaries of the servicemembers' military work experience, 
training history, and language proficiencies. The VMET document also 
includes recommended college credits to be awarded based on an 
individual's military experience and training, as determined by the 
American Council on Education, and related civilian equivalent job 
titles, when such information is available. The VMET Web site, https://
www.dmdc.osd.mil/vmet, is available 365 days a year, and provides VMET 
documents on-demand. Since January 2003, over 1 million documents have 
been provided to current and former servicemembers.
    Since 1999, a DOL platform has been providing employment-related 
information for servicemembers and veterans. DOL established the DOD 
Job Search Web site (www.dod.jobsearch.org). This Web site provides 
employers with a link to transitioning servicemembers' resumes and 
provides transitioning servicemembers with access to job opportunity 
listings with military-friendly employers.
    During the preseparation counseling phase of the Transition 
Assistance Program (TAP), servicemembers learn where and how to access 
information relating to licensure, certification and apprenticeship. 
The Army created ``Credentialing Opportunities On-Line'' or Army COOL. 
This robust Web site helps soldiers find civilian credentialing 
programs related to their military occupational specialty. It also 
helps them understand what it takes to obtain a credential and it 
identifies resources available to pay credentialing fees. In 2006, the 
Navy followed with Navy COOL.
    The preseparation counseling phase also includes a discussion of 
DOL's Web site, ``America's Career Info Net.'' One of the tools on this 
Web site is the Credentials Center, which a servicemember can use to 
locate the examinations that test or enhance knowledge, experience or 
skills in an occupation or profession. Finally, DOD and DOL have 
established a ``Credentialing Working Group'' to develop appropriate 
goals, objectives, and outcomes that will help remove credentialing 
barriers that some veterans and transitioning servicemembers face.
    I want to point out that DOL established the Recovery and 
Employment Assistance Lifelines (REALifelines) as a joint initiative 
among the DOL, the Bethesda Naval Medical Center, and the Walter Reed 
Army Medical Center. REALifelines is designed to create a seamless, 
personalized assistance network to ensure that seriously wounded and 
injured servicemembers who cannot return to active duty are trained for 
rewarding new careers in the private sector. REALifelines staff provide 
employment assistance to severely injured and wounded servicemembers as 
they transition back into the civilian community to fulfill their 
employment potential and dreams. Today, REALifelines has expanded from 
its initial two locations to five additional military medical treatment 
facilities (Fort Carson, Brook Army Medical Center, Balboa, Madigan, 
and Tripler).
    Approximately 300,000 servicemembers have returned to the private 
sector every year since 2001. Of this number, 90,000 per year are from 
the Guard and Reserve. When TAP was initially developed in 1990, it was 
not designed with the needs of the National Guard and Reserve 
Components in mind. Their mission has changed dramatically since 
September 11, 2001, and therefore some TAP requirements warrant a fresh 
look.
    To better meet the needs of the Guard and Reserve, DOD, with the 
assistance of DOL and VA, is designing a new, dynamic, interactive, 
automated, Web-based system for delivery of transition assistance and 
related information. This portal architecture will become the backbone 
of the updated TAP processes. Usability, flexibility, adaptability, and 
individual customization are key to successful implementation of this 
new technology-enabled process. The portal will emphasize and augment 
the personal service provided by our transition counselors, while 
providing servicemembers access to crucial transition-related 
information anytime, anywhere. The goal for this new system is to 
increase servicemember accessibility, participation and satisfaction.
    All three partners are excited about the possibilities for this new 
portal. Its intent is to automate TAP services; standardize TAP 
information; create an external communication link between TAP 
customers and providers, whether DOD, VA, or DOL; and enhance the 
military-to-civilian experience.
    We are also updating our current pre-separation guide for active 
duty personnel, and creating a new transition assistance guide 
specifically for the Guard and Reserve. This effort should be completed 
by the end of February. Both guides will include traditional TAP 
subject matter, as well as links to a wide variety of other transition-
related Web sites. As with the new portal, the Department is heavily 
engaged with all stakeholders, especially our partners at VA and DOL, 
to ensure the information in these guides is up-to-date.
                               next steps
    The JEC will step up its efforts in monitoring the coordinated 
transition process and joint health care facility operations in the 
short term. The newly established Coordinated Transition Work Group 
will concentrate efforts to improve the transition process. This group 
is responsible for ensuring continuity of the service and benefits 
delivery value chain, which, as I've previously mentioned, must be 
characterized by an improved understanding of and access to the full 
continuum of health care and benefits available to servicemembers, 
veterans, and their families.
    The JEC will also be more involved in assisting local initiatives 
that feature joint operations. The newly created Joint Health Care 
Facility Operations Steering Group is a lesson learned from our 
experience with the collaboration between the North Chicago VA Medical 
Center and the Naval Health Clinic Great Lakes. The steering group is 
responsible for providing support to local leadership, identifying 
impediments to collaboration, resolving legal issues, and clarifying 
statutory interpretation.
    The TAP Steering Committee, with representatives from DOD, the 
Military Services, VA, DOL, and the Department of Homeland Security 
(Coast Guard) meets quarterly to discuss and address issues and 
challenges that fall under the transition umbrella. The Committee works 
to find solutions to problems, conduct pilots, and look for new 
initiatives that will enhance and improve our current transition 
program and the overall quality of life of all members of the Armed 
Forces.
    DOD and VA will continue to build on past successes as we move 
forward in Fiscal Year 2007, and beyond. I am proud of the hard work 
and dedication to duty that the professionals within both departments 
display daily as they intensify efforts to increase beneficiary and 
employee awareness, improve existing data exchanges, promote world-
class health care and benefits delivery, and increase the value of the 
Transition Assistance Program to all stakeholders.
    Mr. Chairman, this concludes my statement. I look forward to 
working with the Committee in this new Congress to uphold our 
traditional outstanding support of American heroes--our Nation's 
servicemen and women, veterans, and their families.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Daniel K. Akaka
    Question 1. To what extent have efforts been made to coordinate 
with the Department of Labor to assist returning servicemembers in 
finding meaningful employment in a timely fashion? What efforts has DOD 
made on its own accord?
    Response. The Transition Assistance Program (TAP) Steering 
Committee is the mechanism to coordinate with the DOL to assist 
returning servicemembers in finding meaningful employment in a timely 
fashion. This Committee is comprised of representatives from the DOD, 
the Military Services, Department of Veterans Affairs, DOL, and the 
Department of Homeland Security.
    The Deputy Under Secretary of Defense for Military Community and 
Family Policy, who has oversight for TAP at DOD, collaborated with the 
Assistant Secretary of Labor for Veterans Employment and Training 
Service regarding some new initiatives for this year. Those initiatives 
are outlined below.
                            dol initiatives
    DOL has taken the lead in developing 15 employment assistance 
modules specifically for the Guard and Reserve to receive the 
equivalent of the 2\1/2\-day TAP Employment Workshop that is provided 
at major active duty installations for active component transitioning 
servicemembers.
    In addition, DOL is working to implement a methodology of 
seamlessly ``handing off'' servicemembers directly to a counselor at a 
DOL Career One-Stop Center close to the final destination of the 
servicemember and his or her family.
                            dod initiatives
    DOD staff is preparing a policy change that will strengthen the 
Department's commitment to those servicemembers who want to attend an 
employment workshop. The updated policy will inform Commanders that 
they shall release servicemembers (who request attendance at a DOL, or 
Service equivalent, Employment Workshop) during duty hours to attend 
this important workshop.
    In addition, the Department has contracted with RAND to examine 
recent trends in veteran unemployment rates for 20 to 24-year-old 
veterans in relation to non-veteran counterparts, using administrative 
data on the receipt of unemployment compensation for ex-servicemembers. 
This effort will assist the Department in evaluating its current 
programs and policies with respect to unemployment benefits and the 
effectiveness of current programs aimed at assisting active duty and 
Reserve personnel transitioning from full-time military to full-time 
civilian employment. The study is to be completed in 2007.
    The Department is updating the current active duty Pre-separation 
Guide and creating a new Transition Assistance Guide for the Guard and 
Reserve. We also developed a new Pre-separation Counseling Checklist 
for demobilizing Guard and Reserve personnel.
    The Department developed a Pre-separation Counselor Training 
Course, through the National Learning Center, University of Colorado at 
Denver, to increase the professional proficiency of Pre-separation 
Counselors, by reinforcing the understanding of the requirements and 
how important their role is in the beginning of successful transition.
    The Department established the Interagency Demobilization Working 
Group to specifically address the needs of the Guard and Reserve. As a 
result, DOD is developing a new dynamic Web portal to provide access to 
transition assistance and other related information anytime, anywhere. 
``TurboTAP,'' the Department's nickname for the portal, will enhance 
the existing transition program.

    Question 2. Given the increased obligations of the Guard and 
Reserves, there is a feeling among servicemembers and veterans that 
their education benefits do not match their service commitments. What, 
if anything, is being done within the Department of Defense to address 
these concerns?
    Response. Education benefits under the Montgomery GI Bill for the 
Selected Reserve have long been an effective tool to meet strength and 
force management objectives. Recognizing the increased obligation of 
the Guard and Reserve in an operational Reserve construct, the 
President proposed a new program that provides an enhanced educational 
assistance benefit for Ready Reserve members who have served in support 
of a contingency operation--the Reserve Educational Assistance Program 
(REAP). Congress included this provision in the Ronald W. Reagan 
National Defense Authorization Act for Fiscal Year 2005, which was 
enacted on October 28, 2004. REAP recognizes the additional service 
performed by Guard and Reserve members and provides additional 
financial assistance to accommodate lost educational opportunities 
while activated and a readjustment benefit following activation.
    A key component in both of these programs is that eligibility for 
benefits requires continued participation in the Guard or Reserve. In 
particular, REAP serves as an incentive to remain in the Guard or 
Reserve following the rigors and stresses associated with mobilization 
and time away from families and employers--a time when pressure to 
separate may be significant. It is worth noting that a Reserve 
component member who meets the same service requirements as an active 
duty member is eligible for the same active duty benefit. But not all 
reservists serve on active duty for extended periods, so the REAP 
benefit was designed to provide an enhanced benefit for Ready Reserve 
members who serve on active duty for shorter periods.
    Although there have been some recruiting challenges, the 
Department's success in meeting its recruiting and retention objectives 
suggests that the current educational incentives are having the desired 
effect, coupled with the other recent changes to recruiting and 
retention incentives.
    However, there has been interest in revamping educational benefits 
provided to all military members. One such proposal calls for 
consolidating the three separate programs into a single ``Total Force'' 
benefit. In light of the way we are using the force--active, Guard and 
Reserve--I think it is worth considering some consolidation or 
streamlining of the three educational assistance programs we have 
today. But, we must guard against undermining the original purpose of 
the various programs and their effectiveness in achieving their 
respective program objectives.
    To assess the impact of consolidating the various education 
programs, a joint DOD/Department of Veterans Affairs (DVA) working 
group was formed to examine the possibility of a ``Total Force GI 
Bill.'' This group has been meeting over the past several months.
    The DOD and the DVA, through the Joint Executive Council (co-
chaired by me and Deputy Secretary Mansfield), will review the findings 
and recommendations of the working group, and any legislative changes 
to the various educational assistance programs supported by the 
Administration will be forwarded to Congress.

    Question 3. Please explain the role of the Employer Support of the 
Guard and Reserves in helping servicemembers resume employment post-
demobilization.
    Response. ESGR provides information, education, and informal 
mediation to servicemembers and employers through an ombudsman customer 
service center and grassroots relationships through a network of over 
4,000 volunteers.
    Specifically, ESGR works collaboratively with each of the Services 
to establish a military unit employer support representative throughout 
the Reserve component. This specifically identified servicemember acts 
as the liaison between his or her unit's members and the local ESGR 
military unit liaison volunteer.
    ESGR also helps provide briefings during the demobilization process 
to explain the servicemembers' rights and responsibilities under the 
Uniformed Services Employment and Re-employment Rights Act (USERRA).
    ESGR's aggressive efforts have resulted in a decline of requests 
for assistance with informal mediation to the ESGR ombudsman services 
for the past 3 years, from 486 per month average in Fiscal Year (FY) 
2004 to a 390 per month average for Fiscal Year 2005 to an average of 
262 per month for Fiscal Year 2006. Additionally, although ESGR does 
not have statutory authority to enforce USERRA, it does coordinate 
activities with the three Federal Government organizations with 
responsibility over USERRA--the Veterans' Employment and Training 
Service from the Department of Labor, the Department of Justice, and 
the Office of Special Counsel--in order to better serve servicemembers 
and employers.

    Question 4. How many servicemembers, by year, have been medically 
retired or given a disability discharge as a result of injuries or 
wounds sustained in OEF/OIF?
    Response. The following represents the number of servicemembers who 
have been separated or retired (in the year indicated) under Service 
Secretary authority (Chapter 61, title 10, United States Code) for 
wounds or injuries incurred in the line of duty, associated with OEF/
OIF:

     2003: 332
     2004: 804
     2005: 1,646
     2006: 1,887

    Caveats: Accounting represents those who were awarded a disability 
disposition as a result of:
     Armed conflict or,
     Instrumentality of war.

    Source: Military Department Physical Disability Agencies.

    Question 5. How many OEF/OIF veterans were separated from active 
status (by component--active, Guard and Reserves) between January 2002 
and January 2005?
    Response. The number of OEF/OIF veterans separated from active 
status between January 2002 and January 2005 are as follows:

 
------------------------------------------------------------------------
                                                           Separated/
                       Component                             Retired
------------------------------------------------------------------------
Army Active Duty......................................            47,452
Navy Active Duty......................................            37,197
Air Force Active Duty.................................            20,631
Marine Corps Active Duty..............................            22,804
Army National Guard...................................            21,818
Army Reserve..........................................            12,049
Navy Reserve..........................................             4,021
Air National Guard....................................             5,761
Air Force Reserve.....................................             2,943
Marine Corps Reserve..................................             4,759
                                                       -----------------
    Total.............................................           179,435
------------------------------------------------------------------------
Source: Defense Manpower Data Center.

    Question 6. The 2003 Presidential Task Force to Improve Health Care 
Delivery for Our Nation's Veterans (PTF) recommended that the 
Administration direct Health and Human Services (HHS) to declare the 
two Departments to be a single health care system for purposes of 
implementing Health Insurance Portability and Accountability Act 
(HIPAA) regulations. How did DOD and VA respond to the recommendation. 
How have the HIPAA requirements impacted your health information 
exchange efforts?
    Response. Under the HHS HIPAA Privacy Final Rule, two or more 
covered entities who participate in certain joint activities may 
qualify as an Organized Health Care Arrangement (OCHA), which allows 
them to share protected health information about their patients in 
order to manage and benefit their joint operations. The VA and DOD do 
not qualify as an OCHA under the requirements currently promulgated by 
HHS in the HHS HIPAA Privacy Final Rule. To change those requirements, 
HHS would need to engage in the time consuming process of 
administrative rulemaking. Absent such administrative rulemaking, it is 
our belief that HHS lacks the authority to make such a declaration.
    DOD and VA responded to the recommendation by making maximum use of 
the authority already provided in the HHS HIPAA Privacy Final Rule to 
share protected health information for purposes of treatment at time of 
separation and between covered entities that are government entities 
providing public benefits. Given the existing authority which is 
currently available, which arguably provides for broader protected 
health information sharing than that available to an OCHA, DOD sees no 
benefit in petitioning HHS to engage in administrative rulemaking to 
change the OCHA qualification requirements.

    Question 7. The Departments have indicated that their joint effort 
to develop the interface between VA's and DOD's health data 
repositories is expected to result in the secured sharing of health 
data between the new systems that each Department is currently 
developing and beginning to implement. What measures does DOD have in 
place to protect personally identifiable information that is being 
maintained in its health data repository? How is DOD securing the 
transfer of personally identifiable information from DOD to VA?
    Response. DOD has implemented the following security controls to 
tighten restrictions on access to our network and databases: isolating 
sensitive data from public data, expanding content of audit controls, 
enhancing training, implementing encryption of data at rest and 
updating network devices capability. We are also working with Defense 
Information Systems Agency to incorporate additional monitoring tools 
and intrusion detection devices to identify and address malicious 
activity immediately.
    The exchange of information between DOD and VA utilizes the DOD 
Business to Business Gateway to encrypt the transmission of patient 
identifiable data and incorporates authentication and auditing controls 
into the data exchange.
    The DOD's AHLTA Clinical Data Repository complies with the 
following security requirements:

     DOD Instruction 5200.40, DOD Information Technology 
Security Certification and Accreditation Process (DITSCAP), dated 30 
December 1997.
     DOD Directive 8500.1, ``Information Assurance,'' October 
24, 2002.
     DOD Directive 8500.2, ``Information Assurance (IA) 
Implementation,'' February 6, 2003.
     Public Law 104-191, ``Health Insurance Portability and 
Accountability Act (HIPAA) of 1996,'' August 21, 1996.
     FIPS 140-2, ``Security Requirements for Cryptographic 
Modules,'' May 25, 2001.
     CJCSI 6510.01D, ``Information Assurance (IA) and Computer 
Network Defense (CND),'' June 15, 2004.
     DOD Directive 4630.5, ``Interoperability and 
Supportability of Information Technology (IT) and National Security 
Systems (NSS),'' May 5, 2004.
     Military Health System (MHS) IA Policy Guidance Manual, 
March 5, 2004.
     DOD Regulation 6025.18-R, ``DOD Health Information Privacy 
Regulation,'' January 24, 2003.

    Question 8. How will the Future Military Healthcare Task Force look 
at VA's role when making recommendations about the future of DOD health 
care?
    Response. The Task Force has a representative from the VA (Mr. Bob 
Henke). It is anticipated that where DOD and VA can work together, that 
perspective would be part of findings and recommendations. Although not 
a specific task assigned to the Task Force, partnership with the VA 
remains part of the larger Department agenda under the VA/DOD Joint 
Executive and the Health Executive Councils. Recent agreement between 
the Secretaries of the Departments of VA and DOD have a focus on four 
major areas common to each Department: healthcare planning in joint 
markets; working toward a common Electronic Health Record, starting 
with a partnership on a joint inpatient record; focus on work with 
severely injured traumatic brain injury patients; and, joint work on 
mental health and associated diagnoses including Post Traumatic Stress 
Disorder.

    Question 9. In 2003, the PTF recommended that there should be a 
mandatory physical exam for all separating servicemembers. I understand 
that currently a separation physical is only mandatory for those who 
are retiring. Do you believe that a separation physical should be 
mandatory for all? If not, why not?
    Response. I believe there should be a health screening at 
separation tailored to the military occupation. For example, a tank 
mechanic or jet engine mechanic should receive an occupation specific 
termination health screening at the end of their enlistment or, if they 
move out of that specialty. Currently ``termination'' exams are being 
accomplished across the Services for those individuals in certain 
occupational positions. We should consider the specific military 
occupational position and conduct a tailored screening. Mandatory 
comprehensive physical exams have not been shown to be cost effective 
for health screening.

    Question 10. For VA and DOD, the Joint Executive Council Strategic 
Plan is the primary way by which you advance and measure performance 
and progress. What specific measures are in place to evaluate the 
effectiveness of your efforts?
    Response. The VA/DOD Joint Strategic Plan guides our joint 
activities and serves as the primary instrument by which we measure 
progress and success throughout each year. As a testament to the firm 
foundation that has been established, the guiding principles have 
remained unchanged since their inaugural release in 2004. However, the 
current plan reveals lessons learned in the areas of identifying 
opportunities for improvement, developing goals and strategies to 
achieve these improvements, and developing performance measures.
    The Strategic Plan is at Appendix A of the VA/DOD Annual Report to 
Congress, which will be delivered to the Senate Veterans Committee 
Chairman and Ranking Member by the end of February 2007.

    Question 11. GAO has recommended that attendance at Transition 
Assistance Programs be mandatory for all separating servicemembers, or 
that, at minimum, servicemembers should have the opportunity to 
participate with the support of their supervisors. Do you believe that 
attendance should be mandatory? If the programs were mandatory, does 
DOD have the resources to support it?
    Response. Pre-separation Counseling is mandatory for all Military 
Services and for eligible demobilizing Reserve component 
servicemembers.
    The Department is updating existing policy to allow all 
servicemembers who wish to attend a Department of Labor or Service 
equivalent employment workshop to do so during duty hours.
    DOD supports attendance at Veterans Affairs (VA) Benefits Briefings 
for all eligible servicemembers. The Department has a responsibility to 
ensure all servicemembers are made aware of their VA benefits before 
separation or retirement. The Department is undertaking an effort to 
make transition resources available online. This will allow 
servicemembers who prefer a more hands on, automated approach to get 
the information on VA and other transition related information. The 
online service also will allow servicemembers to access this 
information as the need arises in the future (just-in-time access).
    The Department supports mandatory attendance at the Disabled 
Transition Assistance Program for all servicemembers referred to a 
Physical Evaluation Board and those put in a ``medical hold'' status by 
their Service. We also support a policy that allows members who may be 
separated or discharged with a Service connected disability to be 
released to attend. Commanders should release these individuals during 
duty hours to attend.
    Cost analyses will be conducted by each Department before 
addressing whether sufficient resources are available.

    Question 12. In my view, all transitioning servicemembers should 
receive the same level of service and information, whether they 
separate in the United States or overseas. I am concerned that this is 
not happening. For example, I understand that VA's Overseas Military 
Services Coordinators are only available in Europe for 9 months a year 
and that they are stretched too thin, with only 2 persons covering all 
of Europe at any given time. I understand that in 2006, DOD notified VA 
it could no longer fund this program. What was the basis for that 
decision?
    Response. The Department is committed to servicemembers overseas 
receiving the same level of service as those in the United States. 
Since the implementation of the Overseas Military Services Program in 
1994, coordinators have been available for less than 12 months each 
year. It is our understanding that, effective in Fiscal Year 2008, VA 
will provide coverage 12 months a year.
    Agencies are responsible for providing necessary resources and 
delivering their component of the Transition Assistance Program. DOD is 
responsible for Pre-separation Counseling; Department of Labor is 
responsible for Department of Labor Employment Workshops; and VA is 
responsible for VA Benefits Briefings and Disabled Transition 
Assistance Program.

    Question 13. In September 2005, DOD issued a policy memo to the 
Services Secretaries directing them to provide VA with the names of 
servicemembers entering DOD's Physical Evaluation Board process. I 
understand that in May 2006 this initiative was put on hold because of 
DOD concerns about data security compliance. Why was the initiative put 
on hold and what is its current status?
    Response. Information containing the names, Social Security 
Numbers, and diagnoses of servicemembers referred by Medical Evaluation 
Board (MEB) to Physical Evaluation Board is Protected Health 
Information. Consistent with the provisions of the Health Insurance 
Portability and Accountability Act, transfer of PHI from DOD to VA 
requires that reasonable steps be taken to protect the confidentiality 
of such information.
    In October 2005, the Services' medical departments began to forward 
MEB information to the Office of the Assistant Secretary of Defense for 
Health Affairs, which assumed responsibility for transfer of the 
information to the VA. Such transfer took place via encrypted email 
until mid-2006, when the VA concluded that more stringent measures were 
appropriate to protect the information. The e-mail transfers were 
suspended and the Departments began to weigh several alternative means 
to affect transfers electronically on a permanent basis. In the 
interim, 4 months of data were transferred in the autumn of 2006 via a 
password-protected compact disk, hand carried to the VA. The 
Departments expect to decide upon and implement an improved, secure 
transfer procedure this month.
                                 ______
                                 
 Response to Written Questions Submitted by Hon. John D. Rockefeller IV
    Question 1. Overall Funding Issues. Whenever I can, I try to host a 
roundtable in West Virginia to talk to newly returned soldiers, 
including National Guard and Reservists. I learn a great deal from 
these heroes. I fully support the goals of DOD and VA in improving the 
transition, and many of the policies sound good. But when I talk to 
West Virginia veterans, I do not hear about these policies, I hear 
about problems getting care and delays in service. What is the level of 
new funding committed to these important policies? What are top 
officials in DOD and VA doing to train staff and deliver on the good 
intentions and commitments? Will DOD and VA be seeking additional 
funding to meet the health care needs of our returning veterans?
    Response. The Transitional Assistance Management Program (TAMP) 
offers transitional TRICARE coverage to certain separating active duty 
members and their eligible family members. Under the National Defense 
Authorization Act for Fiscal Year (FY) 2005, effective October 28, 
2004, TRICARE eligibility under TAMP was permanently extended from 60 
or 120 days to 180 days. Estimated TAMP requirements developed for 
Program Objectives Memo (POM) 08-13 are: Fiscal Year 2007--$167M, 
Fiscal Year 2008--$184M, Fiscal Year 2009--$202M, Fiscal Year 2010--
$223M, Fiscal Year 2011--$245M, Fiscal Year 2012--$270M, and Fiscal 
Year 2013--$296M.
    TRICARE Reserve Select (TRS) is a premium-based TRICARE health plan 
available for purchase by qualified members of the Selected Reserve. 
Estimated TRS requirements developed for POM 08-13 are: Fiscal Year 
2007--$127M, Fiscal Year 2008--$381M, Fiscal Year 2009--$563M, Fiscal 
Year 2010--$714M, Fiscal Year 2011--$763M, Fiscal Year 2012--$816M, and 
Fiscal Year 2013--$874M.
    One initiative aimed at increasing the level of familiarization 
among DOD staff with regard to VA is the Family Transition Initiative. 
This group is identifying variations and impediments to maximizing 
patient/family communication, specifically verbal guidance and written 
material provided by DOD and VA staff in anticipation of care 
transition. The group will also provide recommendations to the Health 
Executive Council for improvements in communicating with families. 
There will be an emphasis on sensitivity for the families' prognosis, 
social and economic realities, and flexibility to incorporate 
individual timetable needs.

    Question 2. Timely Access to Care for National Guard and 
Reservists. I have heard from West Virginia National Guard personnel of 
several instances in which the standards you established in your 
October 2003 policy regarding timely access to care have not been met 
for Guard soldiers returning to the civilian world from deployment in 
Iraq and Afghanistan. It appears that the major injuries are usually 
taken care of prior to discharge from active duty, but then after they 
return home, the soldiers slip through the cracks for care recommended 
by their doctors for less critical combat injuries. What are you doing 
to ensure that these combat veterans receive all of the care that they 
need and that their doctors have recommended, and that they receive it 
on a timely basis? Have you established an effective quality control 
system? Is there an appeal or grievance process through the Veterans 
Affairs system. What can be done to meet the health insurance needs of 
our medically retired National Guard members and their families?
    Response. The Community Based Health Care Organization (CBHCO) 
program was created to assist Guard and Reserve servicemembers injured 
in the line of duty to return to their homes where they will continue 
to receive care locally while they are evaluated for return to duty, 
medical release, or medical board. To be eligible, the servicemember 
must have a referral into the program from their respective branch of 
Service. While CBHCO is not available in all States, West Virginia is 
served by the CBHCO located in Richmond, Virginia.
    The Department of Defense (DOD) and VA have separate disability 
determination processes which provide differing economic and medical 
benefits with some overlap between the two. As a result, members often 
pursue both. All veterans with a VA disability rating can enroll with 
the VA for health services. The DOD disability system is, in essence, a 
form of compensation and benefit system for work-related injuries. When 
the member is eligible for services from both agencies, the member may 
choose.
    For 2 years after leaving the military, all combat theater veterans 
are eligible for VA hospital care, medical services, and nursing home 
care for any illness possibly related to wartime deployment, without 
having to prove that their health problems are related to their combat 
service. VA refers to the Certificate of Release or Discharge from 
Active Duty (DD Form 214) as proof of service in a designated combat 
theater of operations to determine this eligibility.
    After 2 years, these veterans may still be eligible for VA care as 
determined by the VA regulations. These regulations generally place a 
member in various priority categories considering type of disability, 
amount of disability, service connection, and the member's economic 
abilities. For Service-connected injuries for which a disability rating 
is received, the VA beneficiary may receive care without cost. He or 
she may be eligible to receive care for non-Service connected 
disability needs at a cost share. The DOD respectfully defers to the VA 
for the details of its programs.

    Question 3. Flow of Information. What can be done to facilitate a 
more efficient flow of communication between military medical 
facilities, to include Community Based Health Care Organization (CBHCO) 
and Military Treatment Facilities (MTF), and the individual state 
Adjutant General when an injured soldier transitions from one duty 
status to another? (From the National Guard's point of view, there 
should be a point of contact clearly identified or established at every 
military medical facility, including CBHCOs and MTFs, who would be 
responsible for notifying the soldier's Adjutant General when the 
soldier is admitted, discharged or transported to another facility. The 
Adjutant General would then assure the delivery of transitional 
benefits access and counseling to include Veterans Affairs healthcare 
options, TRICARE programs that may be available, VA benefits counseling 
such as home loan guarantee, education benefits, and or vocational 
rehabilitation services.)
    Response. I appreciate the opportunity to address this important 
topic. Two options come to mind, each of which requires more 
information from the Army. The first is to assign National Guard 
liaisons to each CBHCO and to each MTF. The second option is to add 
each State Adjutant General to distribution for admission and 
disposition notifications. I defer to the Army for further analysis of 
the efficacy of these options, as well as other possibilities.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. Barack Obama
    Question 1. Aggregate Health Data. I am concerned that the military 
is not giving VA enough concrete data to help them conduct long-term 
planning. Let's take mental health as an example. The Army's Mental 
Health Advisory Team found that soldiers who deployed to Iraq for a 
second time were more likely to suffer mental health problems. Dr. Chu, 
does the Pentagon systematically share information with VA on the total 
number of soldiers who have deployed to Iraq and the number of times 
each has deployed?
    Response. The Defense Manpower Data Center (DMDC) provides a 
monthly list of separated Operation Iraqi Freedom/Operation Enduring 
Freedom (OIF/OEF) veterans to the VA using Service deployment data 
submissions and the DMDC's most current Active and Reserve component 
files. The latest list is a cumulative roster of separated veterans who 
deployed in support of OIF/OEF anytime from September 2001 to November 
2006. Data provided include both the start and end date of each 
deployment that the VA can use to identify the number of times each 
individual has deployed.

    Question 2. Falling Through the Cracks. In an average year, 10,000 
to 20,000 servicemembers are separated from the military through the 
Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) 
process. These are soldiers who, because of physical or mental health 
problems, are unfit to be deployed. How many servicemembers were 
separated from the military last year through the MEB/PEB process? How 
many of these troops had benefits claims filed before they discharged? 
How many had their first Veterans Affairs (VA) medical appointment 
scheduled before they discharged? What kind of comprehensive case 
management is being offered to these troops? What about the 631,000 
total Iraq/Afghanistan vets wounded or otherwise? What kind of one-on-
one transition assistance did these veterans receive?
    Response. The MEB/PEB process is designed and operated by the 
individual Services. The Services monitor the separations within their 
respective personnel communities.
    The VA reported in the VA/Department of Defense (DOD) Joint 
Executive Council Annual Report to Congress on Resource Sharing that, 
as of December 15, 2006, Social Workers Liaisons assigned to Military 
Treatment Facilities (MTFs) had processed 6,714 patient transfers to 
Veterans Health Administration health care facilities. VA Social 
Workers work onsite at the MTF to respond to referrals to coordinate 
inpatient and outpatient appointments at a VA Medical Center near the 
patient's intended residence. They coordinate transfer of care and 
maintain follow-up with patients to verify success of the discharge 
plan, and to ensure continuity of therapy and medications. Case 
managers also refer patients to counselors from the VA who can speak 
about benefits in general, including vocational rehabilitation.
    The DOD has several different programs designed to provide 
assistance to servicemembers as they transition from active duty to 
veteran status. The Army Liaison/VA PolyTrauma Rehabilitation Center 
Collaboration program stood up in March 2005. The intent of this 
program is to ensure that severely injured servicemembers who are 
transferred directly from an MTF to one of the four VA PolyTrauma 
Centers, in Richmond, Virginia; Tampa, Florida; Minneapolis, Minnesota; 
and Palo Alto, California are met by a familiar face and a uniform. DOD 
has a long standing relationship with the VA in which they provide 
rehabilitative services for patients with traumatic brain injuries, 
amputations, and other serious injuries as soon after the incident as 
clinically possible. The role of this Army liaison is primarily to 
provide support to the family through assistance and coordination with 
a broad array of issues, such as travel, housing, and military pay.
    The Joint Seamless Transition Program was established by VA in 
coordination with the Military Services, to facilitate and coordinate a 
more timely receipt of benefits for severely injured servicemembers 
while they are still on active duty. There are 12 VA social workers and 
counselors assigned at ten MTFs, including Walter Reed Army Medical 
Center and the National Naval Medical Center in Bethesda. They ensure 
the seamless transition of health care which includes a comprehensive 
plan for treatment.
    The Military Severely Injured Center (MSIC) operates a hotline 
center which functions 24 hours a day, 7 days a week. servicemembers or 
family members can call a toll free number and speak to a care manager, 
who may become their primary point of contact over time. The Center's 
mission is to augment the Service-specific programs--the Army Wounded 
Warrior Program, the Navy Safe Harbor Program, the Air Force Helping 
Airmen Recover Together Program, and Marine4Life--and work closely with 
each of these programs to ensure seamless care and benefits as long as 
it takes--even after members have left the Service.
    The Center features creative partnerships with the Department of 
Labor and Transportation Security Administration, in addition to the 
VA, and is augmented by field support in the form of a network of 
credentialed Counselor-Advocates who provide face-to-face assistance in 
nineteen locations across the country. Collectively, the personnel 
staffing the MSIC expedite processes help families and alleviate 
complex road blocks for the severely injured. The MSIC also works 
closely with non-government agencies to coordinate local assistance 
programs, such as Heroes to Hometown, in partnership with the American 
Legion and job fairs.

    Question 3. Aggregate Health Data. The Pentagon provides limited 
data to the VA about servicemembers when they are separating, but does 
not provide comprehensive systematic data on the numbers of wounded 
that could help VA in long-term planning. A recent Harvard report put 
the number of American servicemembers wounded in Iraq and Afghanistan 
at more than 50,500. Some of these soldiers are sent to military 
hospitals in the U.S., but many are healed and returned to service. 
Does DOD provide comprehensive real-time casualty figures to VA, by 
that I mean the number injured, medically evacuated, and returned to 
duty every week or every month?
    Response. On a monthly basis, the DOD updates casualty figures on 
the publicly accessible Web site maintained by the Defense Manpower 
Data Center. The Web site includes month-by-month counts of the wounded 
in action (WIA) for each operation. The information is available at the 
following hyperlinks to the site: http://siadapp.dior.whs.mil/
personnel/CASUALTY/OIF-Total-by-month.pdf and http://
siadapp.dior.whs.mil/personnel/CASUALTY/oefmonth.pdf.
    Other monthly reports on the Web site detail the number of 
servicemembers whose injuries or illnesses have required their medical 
transport out of the theater of operation. These data are derived from 
the information system that is used to manage the air transport of 
injured and sick servicemembers. Common diseases that require transport 
include such things as lower back pain, chest pain, vertebral disc 
disease, inguinal hernia, mood disorders, and urinary stones. Common 
non-combat injuries include dislocation of knee, fractures of the leg, 
arm, ankle, and foot and shoulder dislocation. The information is 
available at the following hyperlinks to the site: http://
siadapp.dior.whs.mil/personnel/CASUALTY/OIF-Total.pdf and http://
siadapp.dior.whs.mil/personnel/CASUALTY/WOTSUM.pdf.
    As of January 22, 2007, these casualty data showed the following:

 
------------------------------------------------------------------------
                 Category                      OIF       OEF     Totals
------------------------------------------------------------------------
Injuries Necessitating Medical Air            13,702     2,009    15,711
 Transport................................
    Wounded In Action.....................     6,911       648     7,559
    Non-hostile injuries..................     6,791     1,361     8,152
Diseases Necessitating Medical Air            18,547     3,671    22,218
 Transport................................
                                           -----------------------------
    Total Number Air Transported..........    32,249     5,680    37,929
------------------------------------------------------------------------

    The Web site also includes reports of the total Wounded in Action. 
As of January 22, 2007, the total was 24,476. Of those, 7,559 required 
medical air transport for their wounds. The recent Harvard report used 
erroneous data from a VA Web site to estimate the number of wounded. 
The VA subsequently corrected the data on its Web site.
    All of the information above is readily accessible to the VA as 
well as to the general public; therefore, it is not necessary for the 
DOD to send such data in a special report to the VA. In addition, the 
vast majority of injuries resolve after appropriate treatment and 
convalescence, so reporting to the VA is unnecessary as they do not 
represent a future resource drain for the VA. The more applicable 
reporting would be of ``severe injuries'' that we know will require 
long-term rehabilitation, especially those where the VA will be the 
likely service provider, e.g., spinal cord injuries and amputations, 
but we are still working on how to prospectively identify this group of 
individuals.
    In addition, DOD provides data to the VA on servicemembers who have 
been referred to Physical Evaluation Boards (PEBs). These individuals 
are most likely to have Service-connected disabilities associated with 
their illnesses and injuries and are likely to transition soon to VA 
care after completion of their PEBs. Such data encompass all 
servicemembers, including those who have medical problems associated 
with service in OIF and OEF.

    Question 4. Total Costs of Caring for OEF/OIF Veterans. A recent 
report by the Kennedy School of Government at Harvard put the lifetime 
costs of caring for Iraq/Afghanistan veterans at $350 to $700 billion. 
Do you agree with this estimate, and if not, what estimate can you 
offer in its place?
    Response. This question addresses lifetime costs of caring for 
Iraq/Afghanistan veterans, the biggest piece of which will be 
Department of Veterans Affairs (VA) costs. The referenced report speaks 
to VA medical and disability costs for Operation Enduring Freedom/
Operation Iraqi Freedom veterans. The quoted $350-$700 billion amount 
must, therefore, be assessed in the context of VA costs. Since we do 
not possess VA cost data, we respectfully defer to the VA and suggest 
that this question be redirected to them.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Larry E. Craig
    Question 1. Two years ago, this Committee held a hearing on the 
quality of casualty assistance services provided to the spouses of 
those killed on active duty. We learned about problems in continuity of 
the personnel assigned for casualty services, confusion among survivors 
regarding the array Federal benefits available to them, and 
inconsistencies among the military branches. DOD was directed to 
develop a uniform policy on casualty assistance. Please provide an 
update of DOD's efforts to comply with the law. Are survivors provided 
with electronic access to updated, integrated information regarding 
their benefits?
    Response. The Department takes very seriously its responsibility to 
provide assistance to families of fallen servicemembers and continues 
to explore new methods, procedures, and policies to enhance the current 
level of support or assistance. A guiding principle is this must be a 
zero-defect program and opportunities for improvement must always be 
pursued.
    Subsequent to the hearings of 2005, several policy improvements and 
initiatives were implemented to provide standardized assistance to 
families and eliminate inconsistencies among the Services wherever 
possible. In response to your specific question, ``Are survivors 
provided with electronic access to updated, integrated information 
regarding their benefits,'' it would be helpful if I explain the 
current process and then our plan on the way ahead to address this 
issue.
    The provision of information on all known Federal benefits and the 
availability of financial counseling are currently being provided to 
all applicable survivors and next of kin during the casualty assistance 
process. Information is provided in hardcopy, referral to applicable 
Web sites, and in-person with subject matter experts from the 
appropriate Agency.
    In March 2006, the Department published ``A Survivor's Guide to 
Benefits, Taking Care of Our Own.'' The guide was subsequently updated 
in June and November of 2006 and can be found on the Military HomeFront 
Web site at http://www.militaryhomefront.dod.mil. The guide, developed 
in collaboration with the Military Services, including the Coast Guard, 
the Department of Veterans Affairs (DVA) and the Social Security 
Administration (SSA), details the Federal benefits available to 
families of servicemembers who die on active duty from the DOD, DVA, 
and SSA.
    The Department created, ``The Days Ahead, Essential Papers for 
Families of Fallen Service Members,'' a three-inch binder designed to 
assist families in organizing the avalanche of paperwork that is 
necessary as the family applies for and receives Federal benefits as a 
result of an active duty death. Spouses who receive ``The Days Ahead'' 
notebook will also receive a printed copy of the most recent version of 
``A Survivor's Guide to Benefits,'' and another excellent resource, 
``Military Widow--A Survival Guide,'' which is the first book 
specifically focused on the unique challenges women face when they 
become military widows. This resource is available through Military 
OneSource.
    For the past few years, Service Relief Societies working with the 
Military Services have contracted with a local firm, the Armed Forces 
Services Corporation (AFSC), to purchase a lifetime membership, upon 
request, for eligible family members for AFSC's services. The services 
provided by AFSC include the capability to consolidate all known 
Federal benefits into a single document that also forecasts benefits 
changes over time based on various data changes, e.g., children become 
the age of majority, spouse remarries, etc. Although the DOD does not 
currently have a system such as AFSC's, the critical need for 
information is being addressed in this way.
    The Department is considering alternative options, including 
possibly contracting for this service on a Department-wide basis. The 
Army has developed a Web-based benefits information system called 
``myArmy Benefits,'' which is currently being field tested and 
considered for possible DOD-wide application. In the interim, family 
members will continue to receive high-quality benefits counseling from 
appropriate agency benefits experts at no cost, or, if they accept, 
through services provided by AFSC, which is paid for by the Service Aid 
Societies.
    The Department's policy on casualty assistance, DOD Instruction 
1300.18, ``DOD Personnel Casualty Matters, Policies, and Procedures,'' 
will provide for standardized processes and procedures throughout the 
Department, with the exception of those unique customs and traditions 
of a Military Department. This Instruction is in its final stages of 
formal coordination.

    Question 2. I have learned a lot about the transition experience of 
Idaho's 116th Armor Cavalry Brigade, since their return from Iraq. In 
general, their experiences seem to have been positive. But, I do have 
concern over waiting sometimes as long as 6 months for their post-
deployment health reassessments, understaffed call centers, long 
waiting times for 6-month check-ups, etc. What is DOD doing to improve 
timeliness on follow-up services and care once our Guardsmen and 
Reservists are back in-country and transitioning to civilian life?
    Response. The PDHRA was designed to be completed after the member 
returned home and had time to settle into their civilian life. It is 
conducted three to 6 months after return. In fact, our epidemiological 
research indicates that concerns continue to emerge over the first 
year. It would be ill-advised to complete this assessment earlier than 
3 months after redeploying. This contrasts with the Post-Deployment 
Health Assessment (PDHA), which is completed within 30 days of return 
from theater. The benefit of having an extra post-deployment 
assessment, the PDHRA, is that it allows time for additional concerns 
to emerge, especially those related to reintegration with one's family, 
friends, and community.
    The original contract to conduct the PDHRA for the National Guard 
and Reserves encountered unexpected surges rather than an even demand. 
For example, virtually all National Guard units drill on the first or 
second weekend of each month. Once this issue came to light, we 
implemented changes to increase staffing for those weekends. Initially, 
the Reserves indicated they would prefer to use a call center to 
accomplish PDHRAs throughout the week, but then realized that it would 
be easier for commanders to emphasize the importance of these 
assessments if they were completed at the unit during a drill weekend, 
which was also the first weekend of the month. Again, modifications to 
the supporting business processes remedied the workflow problem.
    The PDHRA is a new clinical process, so we were not surprised that 
we would need to make changes as the process matured. As we identify 
challenges and recognize more responsive ways to complete the PDHRA, we 
make rapid adjustments to meet the needs.
    The DOD requires returning servicemembers to undergo PDHAs to 
document current health status, experiences, environmental exposures, 
and health concerns. The assessments enable health care providers to 
promptly refer those needing medical evaluation and care.
    Completion of the PDHA takes place within 30 days of the expected 
date of redeployment from the theater to the servicemember's home 
station. Use of the PDHA was mandated in an October 6, 1998 Health 
Affairs policy memo. A healthcare provider reviews the form, interviews 
the servicemember and recommends additional clinical evaluation or 
treatment as needed. Copies of the PDHA become part of the 
servicemembers' medical records and are also stored in the central 
electronic database of the Defense Medical Surveillance System. 
Registered health care providers can access electronic copies of the 
PDHA forms via TRICARE Online. Additional post-deployment testing, such 
as serum samples, tuberculosis skin testing, etc., occur at specified 
intervals following redeployment. Post-deployment blood specimens are 
collected within 30 days of redeployment and are processed to produce 
serum that is frozen and archived in the DOD Serum Repository. A PDHRA 
occurs within 90-180 days following redeployment.
    Between January 1, 2003 and December 18, 2006, more than one 
million redeploying servicemembers have completed the PDHA process. 
Approximately 92 percent of returnees have described their general 
health as ``good,'' ``very good,'' or ``excellent.''
    Copies of the PDHA forms are part of the servicemembers' permanent 
medical records, which are provided to the VA through the Seamless 
Transition Program whenever an individual elects for VA care at the 
time of separation or retirement. DOD has successfully developed the 
capacity to add electronic pre- and post-deployment health assessment 
information on separated servicemembers to the monthly patient 
information being sent to the VA. DOD completed a historical data pull 
in July 2005 that resulted in approximately 400,000 pre- and post-
deployment health assessments being transmitted to the data repository 
at the VA Austin Automation Center. Monthly transmission of electronic 
pre- and post-deployment health assessment data to the Federal Health 
Information Electronic data repository began in September 2005. DOD 
added the new PDHRA information to the monthly date feed in November 
2006. As of December 2006, VA has access to over 1.5 million PDHA and 
PDHRA forms on more than 623,000 separated servicemembers and 
demobilized Reserve and National Guard members.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Arlen Specter
    Question 1. Does the Department of Defense consider Post Exchange 
and Commissary services part of the compensation and benefits package 
offered to individuals serving in/retired from the military?
    Response. DOD policy recognizes the commissary and exchange 
services as part of the compensation and benefits package offered to 
active duty members of the Military Services. Because the commissary 
and exchange benefits provide an income effect through savings on 
purchases, the compensation status of the military member is the 
primary determinant when authorizing these privileges. Commissary and 
exchange shopping privileges are extended to Reserve and Guard members, 
retired servicemembers, veterans with 100 percent service-connected 
disability, Medal of Honor recipients, and the dependents of the 
authorized groups.

    Question 2. When do DECA and AAFES plan to release the plan for 
implementing the BRAC 2005 law, related to Post Exchanges and 
Commissaries across the country?
    Response. Commissary and exchange activities are addressed within 
each of the individual installation closure plans. There are no DOD-
wide commissary or exchange plans to implement the Base Realignment and 
Closure 2005 recommendations except that, under DOD policy, 
commissaries and exchanges normally close when the base closes.

    Question 3. Has DECA and AAFES conducted the required study of the 
catchment area and usage levels in the tri-state area (western 
Pennsylvania/eastern Ohio/northern West Virgina) of the Post Exchange 
and Commissary at the Kelly Support Center, Oakdale, Pennsylvania? If 
not, what is the time frame for the study to be concluded?
    Response. No, the Base Realignment and Closure (BRAC) process does 
not require a study of the catchment area and usage levels of the 
exchange and commissary in the tri-state area surrounding the C.E. 
Kelly Support Center. The commissary and exchange at C.E. Kelly are 
scheduled to close when the installation closes by October 2008. 
However, two smaller AAFES facilities in the Pittsburgh area 
(Pittsburgh Air National Guard, 171st Air Refueling Wing and Airport 
Air Force Reserve, 911th Airlift Wing) are unaffected by BRAC and will 
remain open. In addition, if a Military Department were to request 
establishment of new facilities in the Pittsburgh area, that request 
will be evaluated under Department established criteria.

    Question 4. How will this information be used in determining the 
ongoing operation of the Oakdale facility?
    Response. The Base Realignment and Closure process does not require 
a study of the catchment area and usage levels in the tri-state area. 
At this time, there are no plans for ongoing operations at Oakdale, the 
location of C.E. Kelly Support Center. The commissary and exchange at 
the C.E. Kelly Support Center are scheduled to close by October 2008, 
when the installation closes.

    Question 5. As the Army's Kelly Support Center in Oakdale, 
Pennsylvania is the host of the Post Exchange and Commissary, and under 
Base Realignment and Closure (BRAC) 2005 law, the facilities will be 
closing, has any consideration been given to moving the Post Exchange 
and Commissary to an alternate location in western PA?
    Response. There are no plans to open new commissary and exchange 
facilities in western Pennsylvania. As long as sales warrant, the Army 
and Air Force Exchange Service plans to keep two stores at Pittsburgh 
Air National Guard, 171st Air Refueling Wing and Airport Air Force 
Reserve, 911th Airlift Wing. These locations are unaffected by BRAC.

    Question 6. What role can the community serve as the Defense 
Commissary Agency and the Army and Air Forces Exchange Service 
evaluates the future of the Post Exchange and Commissary at the 
Oakdale, Pennsylvania facility?
    Response. The community should contact the Redevelopment Authority 
of Allegheny County, which is recognized as the Local Redevelopment 
Authority (LRA) for planning and directing the reuse of C.E. Kelly 
Support Center, Oakdale, Pennsylvania. The LRA has not proposed 
continuation of the commissary and exchange in the local reuse plan. A 
decision to continue operating a commissary or exchange at a closed 
base is based on established criteria, including the number of active 
duty servicemembers remaining in or around the closed installation.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Lindsey O. Graham
    Question 1. Interagency Coordination. We all support our troops, 
especially those who are disabled as a result of their service to our 
Nation. However, members and their families continue to report that 
they face an overlapping and confusing set of benefits that require our 
injured servicemembers or their family members to navigate, in many 
cases, several large bureaucracies (Department of Defense, Veterans 
Benefits Administration, Veterans Health Care Administration, Social 
Security Administration and Medicare). Because so many agencies are 
involved in the care of our veterans, how do you keep those other 
agencies informed of your efforts, and what is the process to resolve 
problems that exist between agencies?
    Response. While it is true that many agencies are involved, there 
are mechanisms in place to keep all agencies informed of the others' 
efforts and to resolve problems that exist between agencies.
    For systemic issues associated with benefits, transition, or 
support of the severely injured and their families in general, a number 
of councils and programs are in place to facilitate communication and 
cooperation between Departments, as well as serve as the mechanism to 
resolve issues and find solutions to systemic problems.

     The Joint Executive Council (JEC) provides guidance and 
establishes policy for the full spectrum of collaborative activities 
and initiatives between the DOD and Veterans Affairs (VA). The JEC 
oversees and guides the activities of the VA/DOD Benefits Executive and 
Health Executive Councils (BEC and HEC, respectively), as well as their 
many working groups.
     The HEC is responsible for implementing a coordinated 
health care resource sharing program.
     The BEC is responsible for examining ways to expand and 
improve benefit information sharing, refining the process for records 
retrieval, and identifying procedures to improve the benefits claims 
process.
     The Transition Assistance Program (TAP) Steering 
Committee, with representatives from DOD, the Military Services, VA, 
Department of Labor (DOL), and the Department of Homeland Security 
(DHS) meets quarterly to discuss and address issues and challenges. 
They work to find solutions, conduct pilots, and look for new 
initiatives that will enhance and improve the current transition 
program and the overall quality of life for all members of our Armed 
Forces.
     DOD's Military Severely Injured Center (MSIC) augments the 
support provided by the Services programs (the Army Wounded Warrior 
Program, the Navy SAFE HARBOR Program, the Air Force Helping Airmen 
Recover Together Program, and the Marine4Life Injured Support Program. 
The MSIC reaches beyond the DOD to other agencies, to the nonprofit 
world, and to corporate America. It serves as a fusion point for four 
Federal agencies--DOD, VA, DHS Transportation Security Administration, 
and DOL.

    Additionally, to better meet the needs of the Guard and Reserve, 
DOD, with the assistance of DOL and VA, is designing a new, dynamic, 
interactive, automated Web-based system for delivery of transition 
assistance and related information. The Department completed phase one 
of the new site and released a ``soft-launch'' in February 2007. The 
site is called TurboTAP and can be accessed at http://www.TurboTAP.org.
    On February 23, 2007, Secretary Gates established an independent 
review group, co-chaired by two former Secretaries of the Army, Togo 
West and Jack Marsh, to review the care and support for the wounded at 
Walter Reed Army Medical Center and National Naval Medical Center 
(Bethesda). On March 6, 2007, President Bush established a committee, 
co-chaired by former Senator Robert Dole and former Secretary of Health 
and Human Services, Donna Shalala to look more broadly at this issue. 
Both committees will offer opportunities to strengthen support and 
encourage interaction among agencies.

    Question 2. Interagency Coordination. To what extent have your 
agencies interfaced with State government agencies which may also be of 
assistance to severely injured and disabled veterans?
    Response. Through the Department's Heroes to Hometowns program, we 
have partnered with the National Guard Bureau, the American Legion, and 
most recently with the National Association of State Directors of 
Veteran's Affairs (NASDVA) to tap into their national, State, and local 
support systems to provide essential links to government, corporate, 
and nonprofit resources at all levels and to garner community support. 
Support has included help with paying bills, adapting homes, finding 
jobs, education and job training, arranging welcome home celebrations, 
help working through the bureaucracy, holiday dinners, sports and 
recreation opportunities, mentoring, and, importantly, hometown 
support.
    Charter members of State Heroes to Hometowns Committees include the 
American Legion's State Adjutant, the National Guard's State Family 
Program Directors, and NASDVA's State Directors of VA. The intent is 
for severely injured servicemembers and their families to dialogue with 
the State Committee members well in advance of their return home. The 
committee members can then work with their networks in the State and 
local community to coordinate government and non-government resources 
and establish support networks for servicemembers and their families so 
they can live productive lives.
    The American public's strong support for our troops is especially 
evident in their willingness to help severely injured servicemembers 
and their ever-supportive families, as they transition from the 
hospital environment and return to civilian life.

    Question 3. Electronic Medical Records. According to the Department 
of Defense, much more work is needed on development of a comprehensive 
inpatient health care record. What funds have been allocated by the DOD 
and the VA in 2008 to support the development of an inpatient 
electronic record that is compatible and interoperable between the two 
agencies?
    Response. A comprehensive electronic health record (EHR), to 
include inpatient care, is DOD's goal; however, the first priority for 
AHLTA, the DOD EHR, was to address ambulatory care. The AHLTA inpatient 
electronic record development/acquisition is currently targeted to 
begin in Fiscal Year 2010. VA is embarking on a modernization of its 
EHR to include the inpatient component.
    Since both Departments were planning new inpatient electronic 
record acquisition or modernization, DOD and VA are initiating a 
project to work together on a 6-month study to assess the benefits and 
impacts of various alternatives before making a final decision on a 
joint acquisition strategy for an inpatient electronic health record 
system. We anticipate a contract award to a study support contractor 
within the next 30-60 days. The completed study will make a 
recommendation on an acquisition/development strategy for an inpatient 
EHR. The study will provide data needed to determine the acquisition/
development strategy, timelines, impacts on current systems, and 
projected costs. The Departments will then be able to evaluate 
alternatives for funding the chosen technical solution.

    Question 4. Expanded Partnership between the DOD and VA in Health 
Care Services. S. 1042, the National Defense Authorization bill for 
Fiscal Year 2006, as passed by the Senate on November 11, 2005, 
contained requirement for the GAO to study an expanded partnership 
between the DOD and VA in the provision of health care services, 
including an assessment of the advantages and disadvantages for 
military retirees over age 65 and their dependents to participate in 
the VA's health care system. Please share with the Committee your 
thoughts on the potential value of such an expanded partnership, 
especially for military retirees over the age of 65.
    Response. The proposal to shift all retiree health care to the VA 
appears to prohibit their use of DOD Military Treatment Facilities 
(MTFs), and would then be viewed by retirees as a breach of faith.
    TRICARE provides a comprehensive, integrated health care program of 
DOD MTFs and civilian providers for retirees and their families. 
Forcing all retirees to use the VA would be a radical change. All VA 
medical centers can already participate in the TRICARE program as 
network providers, where retirees and their families have the freedom 
to use them voluntarily.
    It is not clear what would be gained by converting a system of 
broad choice of health care providers into a system that makes using VA 
medical centers compulsory. For Medicare eligible retirees over the age 
of 65, under current law, the VA is not able to receive payment from 
Medicare and TRICARE is now the second payer for their care. Thus, if 
this group were required to use VA facilities there would be a large 
cost shift for the care of these individuals which would need to be 
addressed.
    Chairman Akaka. Thank you very much, Dr. Chu.
    Before I begin my questions, I would like to call on 
Senator Webb for any statement that you may have.

                  STATEMENT OF HON. JIM WEBB, 
                   U.S. SENATOR FROM VIRGINIA

    Senator Webb. Thank you, Mr. Chairman. I am sorry I am 
late. We have got three Committee hearings backed up today on 
my schedule, and I very much appreciate your calling this 
hearing.
    I am sorry I missed the other opening statements, but I 
have a long regard for the capabilities of our two panelists 
today. I have known Dr. Chu for many years. We worked together 
in the Pentagon, and I have known Secretary Mansfield 
personally and by reputation, and I know these are people who 
are personally committed to the same things that those of us on 
the Committee are.
    I would like to say one precatory comment, however. I spent 
4 years of my life working every day on veterans issues as a 
Committee counsel on the House side, and the one really 
shocking piece of reality to me returning to this area was the 
bureaucratic stagnation in the VA that I see, and particularly 
in terms of claims. I want to make that one of my priorities to 
find a way that we can streamline this claims process and get 
more energy into it and get the answers out to the people who 
are trying to have their situations resolved. And I will be 
looking forward, Secretary Mansfield, to working with you on 
that.
    I have one other very brief comment. I was present at the 
creation of some of these DOD/VA cooperative efforts. And when 
you were talking about the Chicago situation, we worked on 
that. When I was Assistant Secretary of Defense for Reserve 
Affairs, that was one of our pilot programs. We were looking at 
that in terms of expanding usage of the VA in case we had to 
mobilize. That was one of the things that was on the table. But 
that has been a little more than 20 years since we did that, 
and this is an area where I hope we can, again, really put some 
energy into it.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Webb.
    I have a question for both Secretary Mansfield and Dr. Chu. 
I understand that it may be 2012 before DOD and VA have an 
electronic medical record that can be shared and accessed by 
providers in both Departments. In the year 2003, the 
President's task force believed that this could be in place by 
2005. My question to both of you is: Why is this taking so 
long? Secretary Mansfield, you can respond first.
    Mr. Mansfield. Mr. Chairman, I would agree that this is one 
of the things I have mentioned we have had ups and downs, and 
it has been a combination of problems within the VA, I think, 
and within DOD. The VA system is an old system on an old 
platform that we need to take into the 21st century and 
upgrade. In the process of doing that, it would be good if we 
could work with DOD, and I think the announcement that we will 
hear later on today is that there will be a commitment to doing 
that so that we can agree that the VA has a record system that 
should be usable by both entities, and we can move forward to 
do that.
    As far as the timing, I think part of it has been, as I 
mentioned, we had this universal depository of information 
where the three medical services in DOD could put information 
in, and then we could get the feeds out of that. That was the 
agreement that we were working on for the last 2 or 3 years. We 
can take this quantum leap forward if we agree that we use one 
system, and it is time to do that, and we are going to do that.
    Chairman Akaka. All right. Do you have an idea of when that 
may be?
    Mr. Mansfield. Sir, as always, it is a combination of not 
only the feasibility but also the ability to have the resources 
to make it work, and we are in the process of attempting to be 
able to justify what we need to the Congress of the United 
States, the Appropriations Subcommittees, in an effort to do 
that. I do not have an exact time frame right now.
    Chairman Akaka. Dr. Chu?
    Dr. Chu. I think, Mr. Chairman, that we need to offer a 
little more detail on what has been accomplished.
    First of all, the Department of Defense has transmitted 
just under 4 million electronic records for veterans to VA, so 
there is a major repository of record data there.
    Second, as Secretary Mansfield said, we have initiated as 
pilots what are called bidirectional data exchanges, meaning 
that a provider in either facility, in real time or near real 
time, can look up the ongoing record of the individual. That is 
not a trivial information technology problem given that the two 
Cabinet Departments have very different information technology 
architectures, but it has been demonstrated at a handful of 
sites.
    Third, I do think we would all benefit from some precision 
about what we mean by ``the medical record.'' Do we mean a 
summary of the patient's diagnoses? That is fairly 
straightforward. Do we mean the clinical notes that the 
clinician may have recorded? Which, of course, historically 
were written down. It would have to be transcribed. Do we mean 
actual X-ray images? That is a much more significant data 
requirement and much more difficult to assemble and maintain. 
Do we mean the pharmacological record for the patient? That is 
another set of data.
    So when we say ``the medical record,'' I think what I would 
emphasize is straightforward medical records in large volume 
have been and are continuously being transmitted to VA. The 
real issue going ahead is what Secretary Mansfield indicated. 
Can we create a record that is bidirectional, that is real time 
in nature, and that eventually does append these data storage 
device intensive records like X-ray images? That is a 
significant challenge. We think it can be done. We are 
committed to that goal. It will take time. I do not want to be 
naive about what is required. And I should emphasize, it would 
be the largest--we are already the largest such exchange in the 
country in terms of information. This would take all of that 
endeavor to an even more ambitious level.
    Chairman Akaka. Thank you very much, Dr. Chu.
    I have other questions, but since my time will soon be 
expired, let me ask Senator Craig for the questions he has, and 
we will have a second round.
    Senator Craig. Thank you very much, Mr. Chairman.
    Gentlemen, thank you for your testimony. And, Dr. Chu, 
thank you for broadening the overall understanding of what we 
are attempting to get done here. We look at VA today and see 
its interoperability from center to center with total record 
movement, including X-rays. We assume you can put two wires 
together or wirelessly transmit, and that will happen with DOD. 
Unless you are all on the same electronic system, unless you 
are doing the input, then the transitional time is going to be 
considerable. But what I think is significant--and I am hearing 
it, I am beginning to hear it from both of you--is that work is 
underway. That is what this Committee and this Congress has 
insisted upon, and we are going to stay with it until there is 
total interoperability with these two systems. Then we will 
have accomplished a great deal in time and transition that is 
critically important, and in that process I would trust that 
the active becoming veterans would not fall through the cracks 
in a way that is being expressed today with great frustration 
on the part of many of my colleagues and myself.
    To both of you, many severely injured servicemembers are 
now being disability-retired from active duty, making them 
eligible for TRICARE. Clearly, as service-connected disabled 
veterans, they are also eligible for VA Care. All of us want to 
do whatever is necessary to assist service-connected veterans, 
but I would like to hear from both of you your thoughts as to 
whether your agencies, which are both trying to be all things 
to all severely disabled veterans, are creating some confusion 
and frustration on the part of beneficiaries as well as real 
problems for health care coordination by having dual 
eligibility. Gordon?
    Mr. Mansfield. Yes, Mr. Chairman, a good question. I think 
part of what we are looking at here has to be in the context of 
what the VA has set up and excels in. For example, the Spinal 
Cord Injury Network is one that is nationwide, provides 
individuals the only ability across the country to have the 
same type of care, the same degree of quality of care, and 
allows a spinal cord injured individual to be rehabilitated and 
to be taken care of and to have a long-term care plan for them 
within that system.
    If you look at the Inspector General's recent report--last 
year, I believe, or late the year before--on traumatic brain 
injury, there was a finding in that assessment of the VA Care 
that we were doing as well as and probably better than the 
civilian sector in taking care of traumatic brain injury, with 
the caveat that there was a problem, again, with the long-term 
care. But the IG suggested that we should look at the spinal 
cord injury system again as something to follow in the TBI 
area.
    I think it may well depend on the nature of the injury and 
who has the best ability to make this person as whole as 
possible or to give them the best care or to be able to 
rehabilitate them the best. And I think we have to look and 
make the decision based on that, what is best for the 
individual. And, something that we are learning, dealing with, 
and practicing, is, now we are not just dealing with the 
individual soldier or the veteran; we are also dealing with the 
family. Both the Spinal Cord Injury Network and the TBI Network 
are ones that have included the family in the process of 
designing a care program, moving through it, and having the 
family members understand what is happening and what the 
probable outcomes are. So, I think, those are the issues that 
you have to look at in making decisions about what really is 
best for that individual.
    And then the last issue that you have to deal with that we 
have seen some problems or some issues with is a geographic 
one, because we are not everywhere. We are not everywhere, and 
we cannot deliver care everywhere. So then it becomes a 
question of what the veteran or the veteran's family wants as 
far as where do they want to be and what care can we provide in 
that location.
    Senator Craig. David?
    Dr. Chu. Senator, if I may add to Mr. Mansfield's response, 
first, we recognize that providing people with more choices can 
create some degree of confusion. It is one of the reasons that 
the VA has moved to put counselors into the major hospitals to 
which the significantly wounded return, so that there are 
people on-site who can help people make these choices 
intelligently and with knowledge of what the pros and cons of 
the selection might be.
    Second, we established the Military Severely Injured Center 
to ensure that there was a backstop for all of this, a place 24 
hours a day the families can call and get answers to their 
questions. It is a warm handoff to a human being, to a person 
who is going to deal with the issue at hand, whatever it might 
be.
    Third, as Secretary Mansfield outlined, we recognize that 
the country is better off if the two institutions specialize, 
and so as he suggested, for traumatic brain injury we turn to 
VA. We recognize they are going to be the premier source of 
care for those with significant degrees--there is mild 
concussion and so on. There is a whole gradation, as you 
recognize. I think the clinical staffs of the two Cabinet 
Departments, which do work very closely together on these 
issues, are charting a course of who is going to do what as we 
move ahead. So that while the veteran may select, based on 
geography or personal preference or provider relationship, a 
particular facility--and that is the veteran's right--we try to 
direct people to the areas where they are going to get the best 
result.
    Senator Craig. Thank you.
    Mr. Chairman, thank you.
    Chairman Akaka. Thank you very much, Senator Craig.
    I would like to ask Senator Obama, before I ask Senator 
Rockefeller for his questions, to make any opening statement he 
may have.

                STATEMENT OF HON. BARACK OBAMA, 
                   U.S. SENATOR FROM ILLINOIS

    Senator Obama. Thank you, Mr. Chairman. I just want to 
commend the Chairman and Ranking Member for organizing this 
hearing. I think that we have all been concerned about the 
steps that we need to take to ensure that when our veterans 
come home, that they have got the best possible services 
available. I think that is going to be a heightened concern in 
the years to come, as we have Iraqi and Afghani eterans coming 
home. And so, rather than make a lengthy statement, I will 
submit my statement for the record, if there are no objections, 
and let Senator Rockefeller proceed with his questions.
    Chairman Akaka. Thank you very much, Senator Obama. Your 
statement will be placed in the record.
    [The prepared statement of Senator Obama follows:]
  Prepared Statement of Hon. Barack Obama, U.S. Senator from Illinois
    Thank you, Chairman Akaka and Senator Craig,for holding this 
hearing.
    I'm pleased that the Pentagon and the Department of Veterans 
Affairs have taken some steps to smooth the transition from active duty 
to civilian life. For example, significant efforts have been made on 
behalf of the most severely injured servicemembers. But, when I look at 
the programs and systems put into place to help our veterans and 
compare them to the sheer numbers of servicemembers entering civilian 
life, I'm worried that many veterans--especially, the less severely 
injured and those with mental health problems--will fall through the 
cracks.
    The numbers are overwhelming. More than 630,000 servicemembers who 
were deployed in the War on Terror are now veterans. More than 50,500 
soldiers have been injured in Iraq and Afghanistan. Yet the VA has only 
provided intensive casework assistance to 6,700 severely injured 
veterans. That means that a vast majority of troops leaving the 
military, including many injured men and women, do not have caseworkers 
dedicated to guiding them through the bureaucracy, scheduling their 
first medical appointments, and ensuring their benefits are coming 
through in a timely fashion. This lack of coordination may be the 
reason why fewer than one-third of Iraq and Afghanistan veterans have 
actually sought care at the VA.
    I'm pleased that the Committee will be holding hearings on 
transition, and I hope that the Committee will focus on several aspects 
of this issue.
    First, proper budget planning is critical. A recent Harvard report 
estimated that the total lifetime costs of providing disability 
benefits and healthcare to Iraq and Afghanistan veterans will range 
from $350 billion to $700 billion. The reality, however, is that the VA 
has little idea what those numbers actually will be. Over the last 2 
years, the VA has experienced $3 billion in budget shortfalls, largely 
because it failed to account for the demands of new Iraq/Afghanistan 
veterans. DOD has taken some steps to provide the VA with data on 
separating servicemembers, but has not turned over the information that 
the VA needs to conduct accurate long-term budgetary planning. The VA 
is essentially operating in the dark, and we need to start keeping 
better track of soldiers and potential future demands on the veterans' 
system.
    Second, we need to focus on electronic medical records. I know we 
cannot wave a magic wand and get interoperable health records, or real-
time, two-way information sharing. But the Pentagon has dragged its 
heels in modernizing and sharing data, and veterans are suffering as a 
result. The GAO found that even in cases when DOD facilities set up 
information-sharing agreements with VA hospitals, the system is plagued 
with technical glitches. I've proposed that all servicemembers should 
receive secure electronic copies of their health and service record to 
simplify the process for applying for benefits and health care. I hope 
the Committee will act on my proposal.
    Finally, I'm concerned about the VA's ability to deal with post-
traumatic stress disorder and traumatic brain injury. Thirty-six 
percent of Iraq and Afghanistan veterans treated so far have been 
diagnosed with some kind of mental health condition. Traumatic brain 
injury, the signature injury of the Iraq war, is one we still know 
little about. We need to make sure the VA has the expertise and 
manpower to care for veterans with TBI and PTSD.
    Thank you again Chairman Akaka, Senator Craig. I look forward to 
this hearing.

    Chairman Akaka. I want to tell our witnesses that your full 
statements will be placed in the record as well.
    Senator Rockefeller?
    Senator Rockefeller. Thank you, Mr. Chairman.
    I want to say to our witnesses that I take it as a given 
what most medical journals now say, and that is that the VA 
system as a system is better than our private health care 
system. One of the two of you indicated such in one field, but 
I think it is generally true.
    But there is one major difference. The private health care 
system has a fairly predictable stream of people coming in and 
coming out. The veterans care system is based on, as we say 
these days, surges and they are very dramatic surges, and they 
take catastrophic, you know, substantive forms.
    I think about 25 percent of soldiers who have served in 
Iraq display symptoms of very serious mental health problems. 
On the other hand, almost 80 percent of soldiers serving in 
Iraq and Afghanistan who have exhibited those same traits are 
refused mental health services. If you can refute that, I will 
be happy. Of those who needed services, only 40 percent 
expressed an interest in receiving help. Now, that is an 
important thing because that is human nature, particularly 
human nature among men. They do not like to admit that. It 
comes out in horrible forms later on, but that accounts for 
half of the 80 percent. And, actually, only about 26 percent 
are receiving the mental health care that they need, and that 
is not getting up to the suicide area. That is just regular 
mental health care.
    Now, I would like you to explain that to me. I make it a 
practice that virtually every weekend I go home, I have a no-
pencil, no-press, no-staff, me--alone, my tie on--I will not 
take it off because I am not changing anything I am. So they do 
an ``Arnold Schwarzenegger glasses'' check on me. I pick none 
of them out, and 12 or 13 of them decide that maybe I am OK to 
talk to. And then the most unbelievable surge of PTSD and 
mental health stress, suicidal tendencies come pouring forward. 
I clear my afternoon so these sessions can go 3 to 4 hours. And 
it is unbelievable, to waking up in the middle of the night and 
being convinced that the person lying next to you, who is 
otherwise known as your wife, is, in fact, an Iraqi--an Iraqi 
who has a knife who is about to slice your throat, and you run 
out of the house; to, you know, any clicking door anytime 
during the night, you are on full alert; people moving as far 
away from other people as they possibly can; and just endless 
examples of that sort. Painful, painful. One starts going, the 
others start going. And it incredibly painful, and it grounds 
me in the area of veterans.
    Which takes me back to what Senator Murray said, and that 
is that the President did not mention veterans. And I think 
veterans are sort of--this may be a little bit unkind, but it 
is my impression because I have no other way of expressing it--
that it is a little bit like education or, you know, other 
things that we need to do in this country but after the war is 
over we will get to that. Veterans are a part and parcel--I do 
not have to tell you--of war. And as Jim, I think, said, until 
you do veterans, the war is not complete. Perhaps you said 
that. You do not complete the war.
    So I am just interested in this: number one, what do you do 
about the 40 percent who do not talk about it? You say you have 
specialists over there, and you have specialists at home, and 
they are available. That is what Vet Centers are for, so you do 
not have to go to veterans' hospitals. They are more 
convenient. They are localized. People tend to take their 
families so it becomes cheaper. But they do not express that 
view.
    I can remember in Charleston walking into a Vet Center once 
when there were five gray-suited people that looked like I did, 
and I thought they were all, you know, auditors from the VA. 
Well, they were all there for PTSD appointments. And so 
everybody has their disguises; everybody has their ways of not 
discussing things.
    And so, number one, what do you do about that 40 percent? 
You know what the statistics are. You know what the 
probabilities are. And, therefore, how can you reach out to 
them earlier and later? Because you know they are going to 
explode at some point.
    And then, second--I guess my time is up. I will continue on 
the next round.
    Mr. Mansfield. Well, let me take it from there. Number one 
is that there can be some difference in what the numbers are, 
whether it is 40 percent or 25 percent. The bottom line is 
there is a problem, and we recognized that. And I think you can 
say that DOD has recognized that, and the VA definitely has 
recognized that.
    We recently went through the issue to put in place a new 
mental health plan in an effort to make sure that we had mental 
health practitioners across our system in all our----
    Senator Rockefeller. But is it enough? That is always the 
question. Of course, you have those programs. Of course, you 
attend to those matters. But are there enough of them out there 
to find out the people who have these problems?
    Mr. Mansfield. Well, no, there are not enough. I can tell 
you for people in----
    Senator Rockefeller. Why? Because you don't have the 
budget.
    Mr. Mansfield. In Northfield, Massachusetts, right on the 
Vermont line, the last CBOC that I was up to dedicate, I went 
through that, and we went through the whole 7,000 square feet. 
That is where the primary care practitioners are. This is the 
mental health arena. But we cannot find a mental health 
practitioner that wants to come to this area to practice here. 
So that means----
    Senator Rockefeller. So that is a special problem for you, 
isn't it?
    Mr. Mansfield. It is a problem.
    Senator Rockefeller. That has to do with budget.
    Mr. Mansfield. So that means we have to send the people 
down the line to Northampton to the hospital and have them 
treated down there or try and get somebody from the hospital to 
come out and deal with it.
    So one issue is the ability to get enough practitioners and 
put them in place. That is an ongoing issue, but we have 
committed additional dollars and additional attention from the 
highest level to that to make it work. And I know, Senator, a 
long time ago, you were one of the ones who were saying the VA 
needs to have a mental health practitioner in every one of its 
CBOCs. We are moving toward that, and that is a way of 
recognizing that we do have a problem, we have to deal with it 
and solve it.
    The other issue is that DOD--and David can answer some of 
this--have people on the ground in the combat zone that are 
dealing with this issue, and we have also worked together to 
come up with this joint assessment record that allows us to 
attempt to identify those individuals who may need help, and 
then we can make the offer and start going into the system.
    Senator Rockefeller. But why did you spend $100 million 
less than the $300 million you had on outreach to mental health 
folks last year?
    Mr. Mansfield. Well, part of it may be because we couldn't 
find the practitioner to put in that clinic up there.
    Senator Rockefeller. That is not an excuse.
    Mr. Mansfield. Part of it may be because we are rolling----
    Senator Rockefeller. That is an excuse in----
    Mr. Mansfield. Part of it may be because we are rolling 
out----
    Senator Rockefeller. That is an excuse in the community 
health care system, but it is not an excuse in the Veterans' 
Administration system. That is a unique system for unique 
individuals who render unique services, and that is not an 
excuse.
    Mr. Mansfield. And part of it may be that it is a new 
initiative that we just put the money into. We need to make 
sure that we keep the effort on from the highest levels to move 
this thing out through the organization to make sure that it 
does happen--recognizing from top to bottom that there is this 
problem, we do have to deal with it, it is an important issue.
    Dr. Chu. Senator, if I can come back to two parts of your 
question.
    Senator Rockefeller. Yes. I am way over my time. The 
Chairman is going to shut me up for the next three meetings.
    Dr. Chu. If I might, very briefly, though, respond to two 
parts of your question. First, the numbers, the 25 percent 
figure that you cited, I believe that is a figure that does not 
indicate serious mental health problems. It is the fraction of 
people on the returning post-deployment health assessments who 
indicate any issue that might cause us to follow up as to 
whether there is a mental health issue or not. And that relates 
to the 80 percent figure that you described. It is not that 
they are denied care. In many of these cases, it turns out 
there is not a mental health issue that deserves follow-up. 
That is where the 80 percent comes from.
    Senator Rockefeller. Thank you.
    Dr. Chu. To the latter part of your question, which is 
otherwise to reach out, we recognize that the reluctance of 
Americans to seek mental health care is an important question. 
We are not only pursuing, both DOD and VA, the classical 
remedies that have been employed, which is practitioners who 
are available to see people, but we are trying new routes.
    So, for example, we do have a Web-based self-assessment 
tool that we are publicizing to our people. It allows you 
privately, without any recourse to a practitioner, to ask 
yourself: Do I have an issue? Now, of course, you have got to 
be able to use that tool. That would be the next challenge. But 
it allows privacy, which is what is important to many of these 
situations.
    Likewise, as Secretary Mansfield said, in theater we have 
put mental health teams in the field to ensure that people who 
display symptoms or whose commanders are worried about their 
behavior are seen by appropriate mental health practitioners 
right then and there, again, to try to reach out in a different 
way than we have in the past.
    Senator Rockefeller. Thank you.
    I apologize, Mr. Chairman, very much.
    Chairman Akaka. Thank you.
    May I call now on Senator Murray, and she will be followed 
by Senator Sanders and Senator Obama.
    Senator Murray?
    Senator Murray. Thank you, Mr. Chairman. And thank you to 
both of you. None of us are questioning that both of you have a 
strong commitment to whom you serve, and we appreciate that. 
But you need to understand that the frustration that you are 
hearing comes from us because we do go home to our States, we 
do talk to these veterans, and we can no longer face them with 
the long waiting lines, the lack of care. The veterans, Senator 
Rockefeller talked about, these are people who are frustrated 
we see every week when we go home. And it seems to me when we 
are in a time of war, we should have a heightened sensibility 
within all of your agencies and an understanding that you all 
consider this to be a serious problem that needs to be 
addressed, and take that back to your agencies and the 
Administration, and we see that reflected in the budget back to 
us.
    It is not acceptable to us that money is not used simply to 
save money. We have to make sure these veterans are served, and 
that is the frustration you are hearing from all of us up here.
    And, Dr. Chu, I specifically wanted to ask you, because I 
am concerned about where you are coming from and give you a 
chance to respond, because I was very disturbed to see an 
article in the Wall Street Journal--it is now a couple years 
ago--January 25, 2005, which quoted you talking about benefits 
for veterans. And you said that, ``The amounts have gotten to 
the point where they are hurtful. They are taking away from the 
Nation's ability to defend itself.''
    If that is what you said, that is a gross misunderstanding 
of our obligation to our American veterans, and I could find no 
record of apology or retraction. So I wanted today to give you 
a chance. Do you still believe that keeping our promise to 
American veterans comes at the expense of our military?
    Dr. Chu. That is not what I said, Senator. I never used the 
words ``veterans' benefits.'' Others have mischaracterized my 
remarks that way and never, frankly--sorry. I should repeat 
myself.
    That is not what I said, Senator. I never used the words 
``veterans' benefits.'' Others have mischaracterized my remarks 
in an effort to distort them and to evade the issue. The issue 
I addressed was the award, often by the Congress over the 
objections of both the prior and the present Administration, of 
additional programs to honor individuals who had served a full 
career in the military--in other words, this is not the person 
who serves 2 or 3 years and goes home--who are well compensated 
for their military service, including a significant annuity, 
lifetime subsidized medical care, and so on and so forth.
    What I was trying to point out is that the burden of those 
expenses is starting to eat away at the ability of the American 
military to prepare for its future. That is a real problem. I 
think people inside and outside the Department recognize this 
problem. I regret that my remarks were distorted and 
mischaracterized in a way that suggests an assault on veterans 
benefits. That was not the purpose of my remarks. That was not 
the meaning of my remarks. That is not what I said at the time.
    Senator Murray. Do you agree that caring for our veterans 
is a part of the cost of war?
    Dr. Chu. We owe our veterans care for their injuries, 
support for their transition to civil life, support if they 
have difficulties in that transition, and I support the 
programs that accomplish those outcomes.
    Senator Murray. Well, since we have been funding this war 
through supplementals up to this point, would you agree that 
the supplementals should include funding to meet the needs of 
our veterans then?
    Dr. Chu. The question of what goes into the supplemental 
versus the base budget is a decision made by the Office of 
Management and Budget. I should say that in terms of the 
immediate funding issues that you outlined, as I think Members 
of this body are aware, it is now up to Congress to fund the 
Fiscal Year 2007 budget correctly. There has been talk of 
funding at the 2006 level because of the appropriation issue 
out there. The Administration is seeking to get the Veterans 
Affairs Department funded correctly.
    Senator Murray. Are you not willing to say that it should 
be part of the cost of war, part of the supplemental request--
--
    Dr. Chu. The decisions on budget----
    Senator Murray. [continuing].--or advocate for that?
    Dr. Chu [continuing].--structure are made by the Office of 
Management and Budget. In the end, once Congress appropriates 
the money, which is what counts for the execution of the 
programs, it matters little whether it is in the supplemental 
or in the regular budget.
    Senator Murray. All right. Let me move on. I wanted to ask 
a few more questions. I am very concerned that the VA, 
Secretary Mansfield, is not prepared to care for our Afghan and 
Iraq veterans when they return. As I said earlier, in Fiscal 
Year 2006, the VA planned to provide health care for about 
110,000 veterans from Iraq and Afghanistan, and, in fact, they 
served 185,000. The VA was off by 68 percent. For 2007, the VA 
estimated that 109,000 Iraq and Afghanistan veterans will need 
service. So we see now that the VA is assuming that they are 
going to see even fewer veterans this year than they saw last 
year, and that to me just defies common sense.
    Can you tell the Committee why you think the number of 
veterans served this year is going to be lower than last year?
    Mr. Mansfield. I am not sure which numbers you are using, I 
believe those numbers are the additional new veterans coming 
into the system, and they are added on to the ones that were in 
before. So you are really looking at a number that is 260,000 
or 280,000.
    The other point I would make is that no matter how many of 
them come into the system--and I believe last year, while we 
did have more veterans coming in than we projected--the amount 
of money dedicated to caring for those veterans that was 
expended was less than we budgeted for. So we actually had more 
money budgeted for their care, even considering the one-third 
increase, than we had----
    Senator Murray. I am having trouble following the logic, 
but just for this Committee----
    Mr. Mansfield. It is a report that I can make sure that we 
get to you and show you, Senator.
    Senator Murray. What is the total number of veterans that 
you expect to see this year?
    Mr. Mansfield. I am sorry. I did not prepare to bring that 
number with me, but I can ask some personnel.
    Do we have that in a budget sense?
    It is going to be in the same range that we were talking 
about before, with some adjustment for what we have seen in the 
last couple of years.
    Senator Murray. Well, as I mentioned earlier as well, in 
Friday's Houston Chronicle Secretary Nicholson said that the 
deployment of 21,000 more troops to Iraq will have a minimal 
impact on the VA. Most of the veterans that I talked to at 
home, who are frustrated, disagree with that. And I would like 
to ask both of you what the impact of this surge will be on 
transition assistance, on health care waiting lists, and 
benefits backlog and, subsequently, what you are going to do to 
minimize the impact of this.
    Dr. Chu. If I may, Senator Murray, I think the source--I am 
merely speculating. I have not talked to Secretary Nicholson. 
Maybe Mr. Mansfield has more insight here.
    I presume the source of his comment is the fact that we 
enjoy and attribute, really, to young Americans today, we enjoy 
very high retention rates in both the active and Reserve 
services of the United States. So a high fraction of those who 
have served in Iraq and Afghanistan or in other theaters around 
the world in the Global War on Terror are still in military 
service. They are not, with some modest exceptions, eligible 
for the various benefits that you described. So I presume that 
is the basis of his statement. Most of the people who join the 
military today stay with the military today.
    Mr. Mansfield. I think part of it, too, Senator--and this, 
of course, is a macro view, and you are talking about talking 
face-to-face with the individual at that level. But we treated 
approximately 5.3 million individuals during the course of last 
year, so the effect of 21,500 more and what percentage from 
there that may come into the system becomes a smaller number.
    But the issue you raised is to make sure that we can get 
those people in the system and access to and in a timely manner 
is the issue that we really have to pay attention to.
    But I would reiterate that last year the amount of money 
budgeted for care for Iraqi and Afghani returning veterans 
expended was less than was budgeted for, even though the number 
was higher. The reports show that.
    Senator Murray. Well, Mr. Chairman, I hope we can really 
look at that because that is disconcerting to me, that if we 
are budgeting money, we already know we have underbudgeted, and 
then we are not spending that money, we are saying it is less. 
Why are veterans not getting this care? Is it because of the 
waiting lines, they do not get in, and so they do not impact 
the budget? Is it because we are not reaching out and trying to 
find these veterans, as Senator Rockefeller was talking about, 
with PTSD? So, you know, obviously, they are not impacting the 
budget if they are not getting the services they need.
    I hope we can really take a look at that. I am very----
    Mr. Mansfield. The returning veterans, new veterans for 
their first appointment are getting in generally within the 30-
day period that we have set aside. And if it is an emergency 
care----
    Senator Murray. We are hearing a 6-month waiting list to 
get in for primary care.
    Mr. Mansfield. Well, I would like to follow up with you, 
Senator, and find out exactly, where and when that is and see 
what we can do to fix it then.
    The information I receive on a monthly basis says that for 
98 percent we are getting them in within 30 days. The area 
where we have a problem, which I would admit, is the specialty 
care arena, where it is taking longer than we have planned for 
to get them into the next step.
    Senator Murray. And could you tell us, if you do not have 
it today, how many Iraqi veterans are enrolled today in the VA?
    Mr. Mansfield. I do not have that with me, but I can 
provide it for the record very soon.
    Senator Murray. Thank you.
    Chairman Akaka Thank you, Senator Murray.
    Senator Obama. Mr. Chairman, I apologize to Senator 
Sanders. Unfortunately, I have got a Senate Foreign Relations 
Committee meeting as well, so what I'd like to do is just 
submit my questions to the record. I apologize that I am not 
going to be able to ask questions. But if Dr. Chu and Mr. 
Mansfield would be willing to have their offices respond, that 
would be helpful.
    Thank you very much.
    Chairman Akaka. Thank you, Senator Obama.
    Senator Sanders?
    Senator Sanders. Thank you, Mr. Chairman.
    I think the key aspect of this discussion that we have been 
having this morning is that there are some of us up here who 
think that, among other things, the VA is significantly 
underfunded and is not responding in a timely manner or as 
effectively as it might to the needs of veterans.
    I would like to ask Mr. Mansfield, Are you and the 
Secretary going to recommend to the President a substantial 
increase in funding for the VA?
    Mr. Mansfield. Senator, we go through a process in internal 
budgeting which allows us to figure out how many people we 
believe we will need to take care of, and then we ask for the 
money to take care of them.
    Senator Sanders. Right.
    Mr. Mansfield. So we have asked for and we have been 
granted, although it has not gone through the total process, 
significant additional dollars in the last number of years.
    Senator Sanders. Yes, but the needs, as you have heard--we 
are in the middle of a war, so it is not a surprise that we use 
additional dollars. My question is: Are you going to ask for 
substantial increases in funding for the VA to address the 
needs that you are hearing today for the veterans of this 
country? Can we expect the President to say we have a serious 
crisis, we are going to take care of veterans, and to do that, 
we are going to substantially increase funding? Are you going 
to make that recommendation, sir?
    Mr. Mansfield. Sir, I would make the point that we would 
ask for what we believe we need to get the job done.
    Senator Sanders. Do you believe that we need substantial 
increases in funding?
    Mr. Mansfield. I believe that we need some increases in 
funding and that we have asked for substantially that amount. 
Again, if----
    Senator Sanders. Well, it sounds to me, sir, like a non-
answer, to be honest with you. Let me ask you another question, 
though.
    Last year, in the President's budget, as I recall, he 
proposed doubling the costs of prescription drugs for our 
veterans, and he also proposed a substantial increase in the 
fees for many of the veterans. And, I believe, studies 
indicated that the increase in fees would drive some 200,000 
veterans off of VA health care. Can we expect the President 
again to ask veterans of this country to pay more for their 
health care?
    Mr. Mansfield. That I do not know, sir.
    Senator Sanders. Do you think that that is a good idea?
    Mr. Mansfield. I think that we presented an argument that 
showed across the board that there was unequity issue tied in 
to people that have served 3 or 4 years and are entitled to 
care and those that have served 20 or 30 years and are in the 
TRICARE arena and have to pay certain amounts to get the 
benefits there.
    Senator Sanders. So what we are doing is saying some 
veterans are in need, more in need, and maybe we should drive 
some veterans off of VA health care. Do you think that is a 
good idea?
    Mr. Mansfield. Well, I would tell you, sir, I do not 
approach this with the idea that we are driving anybody off 
of----
    Senator Sanders. Well, the studies seem to indicate that if 
you propose--I believe it was. I may be wrong on this. Somebody 
can correct me. Was it a $250 increase in fees? Does that sound 
right? And I believe that I read that would result in driving 
hundreds of thousands of veterans off of VA health care? Do we 
think that is a good idea?
    Mr. Mansfield. I do not believe that the words ``driving 
people off of VA health care'' is, again, the approach that I 
would have taken to any of these----
    Senator Sanders. But if that is the--well, let me go back 
again----
    Mr. Mansfield. People make decisions based on economics 
about which----
    Senator Sanders. They sure do. And if they do not have much 
money and they have to pay $250 to get VA health care, you know 
what some of them will do? They will say, ``I am not going to 
go into VA health care.'' Won't they? Do you agree?
    Mr. Mansfield. Yes.
    Senator Sanders. My question is: Are you going to recommend 
to the President not to increase fees for VA health care and 
not to double prescription drug costs? That is my question.
    Mr. Mansfield. We are in the process, sir, where a budget 
has been put together and will be presented at an appropriate 
time here on the Hill in the immediate future.
    Senator Sanders. Well, Mr. Chairman, I think the difficulty 
is that we have some of us here who think that our veterans are 
in need of more help than they are getting. We would like to 
see the VA budget adequately funded, and some of us are a 
little bit disturbed that the VA is not there demanding that 
the President provide the kind of resources that, in fact, we 
need.
    I would yield back. Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Sanders.
    As you know, this oversight hearing is on collaboration and 
cooperation to meet the needs of returning servicemembers, and 
these concerns will be dealt with in this Committee.
    To the second round of questions, this is to Secretary 
Mansfield and Dr. Chu. Since 2002, OMB has lowered the grade 
from green to yellow for the President's Management Agenda 
Initiative on coordination between VA and DOD.
    Secretary Mansfield, you first. What explains this drop in 
grade? And what is VA doing to improve performance?
    Mr. Mansfield. Sir, I believe part of it is the fact that 
the VA/DOD cooperation element was included in the President's 
Management Agenda for the first time only a year ago, and there 
is a process where they start out at the bottom, so you start 
out red and then you have to come up from there.
    The other point I would make is that Dr. Chu and I agreed 
when the JEC considered the plan that we offered, which was 
then looked at by the folks in the President's Management 
Agenda to make the grades, we would rather reach as high as we 
could and set the bar as high as we could in an effort to make 
sure that we could go forward in a way to meet the full needs. 
So we did not back off of that and put in a lower-level plan. 
We put the bar as high as we could in an effort to make sure we 
were trying to drive this effort forward to the fullest degree 
we could. And that meant that on some of those issues, we did 
not get the accomplishment that we hoped for.
    Chairman Akaka. Dr. Chu?
    Dr. Chu. If I may add to Secretary Mansfield's response, 
the OMB grades typically reflect progress against a set of 
milestones. So in Period 1, if you get green, it means you have 
met the milestones for that period. In Period 2, much as 
Secretary Mansfield outlined, you have a new set of milestones. 
And if you do not meet all those milestones, you will not get 
quite as good a grade.
    It is intended to call management's attention to areas that 
need reinforcement. We have done that. I think you will see the 
next grades will look better as a result.
    Chairman Akaka. Secretary Mansfield and Dr. Chu, there are 
many programs in both DOD and VA that work with those who 
suffered serious injury in Iraq and Afghanistan. There is DOD's 
Military Severely Injured Joint Support Operations Center. The 
Army has its Wounded Warrior Program. The Marines has the 
Marines4Life Program. The Air Force has its Helping Airmen 
Recovery Together program. The Navy has SAFE HARBOR. In VA, 
there is a National Polytrauma Rehabilitation Call Center 
Helpline.
    Dr. Chu, you first. What is being done to ensure that these 
programs are considered? And how is their effectiveness being 
measured? How are servicemembers and their families being 
helped in figuring out where to seek assistance? Dr. Chu?
    Dr. Chu. Mr. Chairman, it is a pleasure to address these 
programs because they are important to the rehabilitation and 
return to full productive life of our veterans who have 
suffered significant injuries.
    The separate service programs are stronger now than they 
were before. Therefore, the Severely Injured Center that you 
described will start stepping back as the services start 
stepping forward, each in its own lane to care for its own 
people. That is a model of decentralized effort that I think 
responds to some of the concerns Members have raised here this 
morning. Each service is closer to its people. There is a 
cultural affiliation, a warmth, a caring that is, I think, 
ennobling in terms of what they do. So we want the individual 
services to play a strong role.
    Now that they are more prepared to do so, we will step 
back, and, in fact, we will rename the Severely Injured Center 
as part of the Military OneSource Center, which is our broad 
outreach program to military families for all issues.
    The Veterans Affairs Department has a close liaison with us 
in these programs. As I indicated, it puts counselors in places 
like Walter Reed and Bethesda and other significant military 
hospitals around the country. There is a very strong 
partnership between the two.
    It is important to allow the veterans to choose how they 
best like to be cared for. Even if clinically we might have one 
recommendation, ultimately the choice of how they wish to 
proceed is theirs, and our responsibility is to ensure they 
know about those choices and can make a considered, thoughtful 
decision, that the bureaucracy is facilitating rather than 
standing in the way of their progress. And I think we have got 
quite a good track record. That is ultimately the measure: Are 
the families satisfied, are the veterans satisfied with the 
care that they are receiving? I think you have seen in news 
media reports the very fine remarks that those with severe 
injuries have given to the care they are getting at Walter Reed 
and Bethesda.
    Chairman Akaka. Mr. Mansfield?
    Mr. Mansfield. Mr. Chairman, I would just make the point 
that, going back to the initiation of these programs, the VA 
cooperated with the Secretary of the Army and the Commandant of 
the Marine Corps originally to put these programs in place. 
Also, we cooperated with Dr. Chu to put VA people in the OSD 
office in an effort to make sure these programs went forward.
    We recognize that after a severe injury that causes the 
person to be removed from the battlefield in some cases, or in 
other circumstances, to a military treatment facility, then 
they are faced with the question of what happens next, the fact 
that they may be leaving the service is another issue that we 
have to deal with, and it is something that they worry about. 
And I know this personally from my own background and what 
happens as you go through this process.
    We have the social workers and the benefits counselors from 
the VA in Walter Reed or Bethesda to help that transfer and to 
work with that individual, that man or woman who is injured, as 
well as their family. This is a way to ensure that we have the 
representatives from the services in the VA facility.
    For example, yesterday, in preparation for this meeting, I 
met with the colonel from the Marine Corps and a representative 
from the Army who are in VA headquarters prepared to deal with 
any issues that come up from these seriously injured 
individuals as they make that transfer to a VA facility, to 
make sure that they do not get lost in the cracks, any issues 
they have that come up will be dealt with. So I think it is a 
very good way to make sure that this seamless transition is 
covered on both sides--the military treatment facility, DOD; 
the VA medical center, the VA.
    Chairman Akaka. My time has expired.
    Senator Rockefeller?
    Senator Rockefeller. I want to reflect a little bit on the 
Guard and Reserve. The third largest complaint of these 
listening sessions that I go to, if I may be frank about it, is 
the disdainful condescension of the regular military toward the 
Guard and the Reserve, which represents a large part of what 
West Virginia soldiers are doing in Afghanistan and Iraq.
    Now, I do not attribute that to either of you two. Gordon, 
you have been in my house many times. We are very good friends. 
You are now representing a different client than you used to 
be. Dr. Chu, I do not know you. But our General of the Reserve 
component remembers--feels that the following standards should 
be: no longer than 1 week for non-urgent routine medical care. 
Do you think this is possible?
    Dr. Chu. Sir, are you speaking to me or to Mr. Mansfield?
    Senator Rockefeller. I am sorry?
    Dr. Chu. Sir, are you asking me or Mr. Mansfield?
    Senator Rockefeller. I am asking you.
    Dr. Chu. For VA treatment or for----
    Senator Rockefeller. Yes.
    Dr. Chu. I really would not be competent to speak to what 
the VA standard ought to be.
    Senator Rockefeller. Secretary Mansfield?
    Mr. Mansfield. A person needs an appointment and they 
should get it in 1 week; is that the question?
    Senator Rockefeller. Yes.
    Mr. Mansfield. The Commander of the Reserve believes that?
    Senator Rockefeller. For routine medical care.
    Mr. Mansfield. In the VA.
    Senator Rockefeller. In the VA.
    Mr. Mansfield. These are folks that have now qualified for 
VA care?
    Senator Rockefeller. Correct; otherwise, they would not be 
there.
    Mr. Mansfield. So they are out and about. The standard we 
have, sir, is 30 days for the initial appointment, and if it is 
emergent care, then it is taken care of immediately. So it is 
longer than 1 week. It could potentially, depending on----
    Senator Rockefeller. OK. The second part of his question is 
no longer than 1 month for specialty care, which includes, of 
course, surgeries. Do you know that is possible?
    Mr. Mansfield. No, sir. Right now, it is not. Specialty 
care is an area, as I mentioned earlier, I believe, where we 
have problems meeting our current standards, and we are 
stretching times on that right now.
    However, I would make the point again that my medical 
advisers continue to tell me emergent care or an obvious need 
right away would be taken care of right away.
    Senator Rockefeller. Do you know what I think this all 
comes down to, Mr. Mansfield? It comes down to the fact that, 
other than the Pentagon--and perhaps including the Pentagon--
the Veterans' Administration is the largest agency in 
Government. Now, that may be true of CMS and not the VA, but in 
any event, it is in the top two or three.
    Your answers to questions here today were that you have to 
do the best you can and you have to work through the 
``process,'' a word which you used. The process is as follows: 
Every word that you spoke to us from your prepared testimony 
and every word that you spoke to us, Dr. Chu, from your 
prepared testimony--well, particularly you, Mr. Mansfield; I 
don't know about Dr. Chu--was vetted by the Office of 
Management and Budget. That is the way the system works around 
here. You do not get to give what you think. You get to give 
what the company line is. I want people to understand that.
    So that when we ask you, ``Do you think people are getting 
enough service?'' You have to say, ``Well, we are doing the 
best we can,'' or ``Yes,'' or as they used to say when I went 
to Iraq, ``We have enough troops to accomplish the mission, 
sir''--which meant that they did not.
    Now, in this system where the OMB--and I do not know how 
many trips they make out to Iraq, and I assume they do make 
trips out to Iraq and Afghanistan. But they can only give you 
what they are told to give you, what the budget parameters of 
that year will allow them to give to you, which, by definition, 
means that the veteran is put into a second position, the 
recipient position.
    So there is only one way out of that. I tried it once on 
Vice President Gore, and it worked, because being Vice 
President is called ``up there.'' And I had an issue on 
veterans health care, and I proposed to make a stink about it, 
and I called him up, and I said, ``Does the Government have any 
more money than this in the budget?'' Well, the OMB budget had 
already been drafted. And he was not pleased by my phone call, 
was not pleased by me, and, nevertheless, at the end he yielded 
and the budget number went up.
    Last year, Danny Akaka and Patty Murray led the fight, not 
for the $3 billion which should have been the increase in the 
veterans care budget, for the $1 billion which they thought 
they could get. That overruled the OMB in that part of the 
process because it was, as you said, appropriated, voted, 
legislative funds, passed both Houses.
    So, if Senator Akaka had not done that, if Senator Murray 
had not done that, you would have a $1 billion shortfall, which 
then leads to the question: What do you all do about it? You 
are the ones--and I like you a lot. I respect you a lot. You 
know that. In spite of the tone of my questioning, you know 
that. And so the question is then: What do people like you and 
Dr. Chu do? Or what does somebody like Jim Nicholson do?
    There is only one recourse for him, and he can only use it 
once. And in the case of the veterans, I am not sure that he 
would have to use it more than once, and that is, he walks in 
to the President and he says, ``If I do not get $3 billion 
more,'' or ``X'' billion dollars more, or whatever it is, for 
mental health, for suicide prevention, for getting that 80 
percent--the 40 percent of which do not declare themselves, but 
which an experienced eye can tell signs of out there in the 
field, much less back here. He says, ``If I do not get that 
money, I am going to quit. And I am going to quit and I am 
going to tell the public why I quit.''
    That has an amazing effect on a President, I would guess. 
Veterans, Iraq-Afghan War--or, rather, Afghan-Iraq War is the 
central subject of our times and that, unfortunately, is the 
limit of the process. I can make a phone call to Gore, if I 
happen to know him and if it happens to work. I was Chairman at 
the time. We can legislate, you know, override OMB and we can 
legislate.
    You do not play a part in either of those, but you are the 
folks on the line. You are the guy who got the medal. You know 
what it is. So you are put into a position where you really 
cannot speak up for the veteran except for the money that is 
appropriated to you, which is never, under Democrats or 
Republicans, sufficient. Because always to this point, veterans 
have been considered by the body politic to be a subsequent 
matter, a subsequent item.
    Now, all of a sudden they are not. Maybe that began with--
was it Rebecca Lynch? Hmm? Jessica Lynch--of West Virginia, no 
less. And she became sort of the voice, the image of the 
veteran, and then it progressed up from there.
    How many was it that were killed yesterday? Was it 79, in 
the last 2 days, 79? They will not be veterans. But others were 
wounded; they will be veterans. They now have these Iranian 
IEDs that put all these long shards of metal into you, and you 
live, but you probably wish that you did not because the pain 
is so horrible and so chronic, and it rests with you for the 
rest of your life because they cannot take those shards out 
because they are too close to vital veins and organs. So you 
live in agony for having served your country.
    You understand my point. I simply say that there have to be 
some people who are willing to put themselves on the line. 
Danny did. He could have lost. Veterans could have said, ``Oh, 
he did not try hard enough.'' They would not have said that 
about Danny, the Chairman. But he did it and he won. And Patty 
Murray, the schoolteacher in tennis shoes, did the same thing, 
and she won.
    Now, if they can win, so can you. Your concern is 24/7 
about these folks, all the time. That is all you think about. 
You bleed with them. You cry with them. You hug them. And you 
think about what you have to do to make their lives better. But 
you cannot, because you are under the thumb of the Office of 
Management and Budget. You are ruled by them--unless you find a 
way to supersede them, which is what I ask you and us to do.
    I thank the Chairman.
    Chairman Akaka. Thank you very much, Senator Rockefeller.
    Let me close with a question to Secretary Mansfield. As you 
know, Secretary Mansfield--and we are talking about being on 
the line, and I feel that Vet Centers are on the line for the 
VA. And I have been working over the years to increase funding 
for the Vet Centers. I view the services they provide as being 
very, very critical to the mission of the VA.
    My question to you: Are the Vet Centers effectively 
connecting with returning servicemembers? Does VA have 
sufficient resources to meet the demand that these returning 
servicemembers will place on essential programs through the Vet 
Centers, Secretary Mansfield?
    Mr. Mansfield. Mr. Chairman, I would make the point that in 
my travels as I go out to VA facilities, I do try and visit Vet 
Centers every chance I get. And in the ones that I have visited 
lately over the course of the last year, in each and every one 
of them there have been Iraqi veterans present for the effort 
going forward or ones that have come in and signed up.
    We have twice gone out and made an effort to hire Iraqi 
veterans to bring them in for peer counseling, and each time 
that I visited a Vet Center, I have heard from those 
individuals, and they are going out, for example, to the 
National Guard units that they know about because they are from 
the town, or maybe they were from that unit, to the Reserve 
units, as well as active-duty units that may be in the area, 
and attempting to make sure that the Iraqi and Afghan veterans 
are aware of the services provided.
    I believe--and I have asked the question of my medical 
advisers--that they are funded sufficiently to get the job 
done, recognizing that we have given them additional people to 
get the job done. And I believe that we are adding significant 
numbers of new Vet Centers over the course of this Fiscal Year, 
should we get a budget, and also next year, in an effort to 
make sure we continue to reach out.
    The one issue that still comes up and that I am aware of 
is: Are we doing enough for family counseling? There have been 
some efforts to require that we get qualified or certified 
family counselors involved in the process for the effort to 
deal with the family members present. Right now, I think the 
approach is, these are Vet Centers and we are there primarily 
for the veteran. We do recognize that having the family 
involved helps the veteran, again, to get whole or get better, 
and we are making an effort to review that issue and come up 
with some final answers.
    I think we are doing a good job in that area. I know that 
there are a lot of Iraqi veterans that are coming in and are 
being helped. And in addition to that, we have also, as of 2 
years ago, started doing bereavement services. I have been in 
some Vet Centers where families of veterans who are deceased 
have been brought in, and they are having groups of them to 
help them through the bereavement process.
    So they continue to expand the work they do, and the issue 
of families, I think, is paramount in all that we are doing 
when we are talking about Iraqi or Afghan veterans.
    Chairman Akaka. Our country is facing huge challenges when 
it comes to our veterans, and I am so glad you mentioned 
families. We need to extend it to them because families affect 
our troops wherever they are.
    There is no question that collaboration and cooperation is 
needed between Congress and the Administration, as well as 
between VA and DOD. We need bipartisan support in all of these, 
but the huge challenge is that we need to provide the kinds of 
services that are being demanded by our veterans, and many 
problems that arise. One of them is resources, funding, and we 
have talked about this today, the need to do that. And we need 
to find ways of doing it because with more resources we may be 
able to provide better services.
    There is also a need to look at and restructure what we 
have now in the VA services so that we can better serve the 
veterans. So many of these challenges now face us, and today is 
the beginning of all of that. And today's hearing has been on 
collaboration and cooperation, and I mention that to you in the 
spirit that we want to try to work together to help the 
veterans of the United States of America. We owe it to them, 
and they need all the help we can give them.
    I want to thank you, Secretary Mansfield and Dr. Chu, for 
your testimony this morning. I do have a request. At these 
hearings, we often are unable to ask all the questions we would 
like, and as a result, we end up sending you post-hearing 
questions, as was mentioned by Senator Obama. And I do and 
other Members have post-hearing questions.
    The record will be open for 2 weeks for submission of post-
hearing questions. In the past, we have experienced difficulty 
in getting timely responses to post-hearing questions. I would 
like your assurances that you will do everything within your 
power to ensure that reasonable response times are met.
    Also, if you would each designate one point-of-contact 
person for any future questions on this subject, we would 
really appreciate that.
    Mr. Mansfield. Thank you, Mr. Chairman. You have my 
assurance.
    Dr. Chu. Thank you, Mr. Chairman.
    Chairman Akaka. And so, again, thank you for your 
responses, and this hearing stands adjourned.
    [Whereupon, at 11:24 a.m., the Committee was adjourned.]



  

                                  
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